Provider Demographics
NPI:1336230010
Name:NTEGROUS CORE CORPORATION
Entity Type:Organization
Organization Name:NTEGROUS CORE CORPORATION
Other - Org Name:ANDERSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANNUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:626-398-1696
Mailing Address - Street 1:1864 E. WASHINGTON BLVD #105
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104
Mailing Address - Country:US
Mailing Address - Phone:626-398-1696
Mailing Address - Fax:626-398-9860
Practice Address - Street 1:1864 E. WASHINGTON BLVD #105
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104
Practice Address - Country:US
Practice Address - Phone:626-398-1696
Practice Address - Fax:626-398-9860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY34307333600000X
3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA343070Medicaid
CA1336230010Medicaid
CA0619160001Medicare NSC