Provider Demographics
NPI:1336373646
Name:DOMINGUEZ PHARMACY LP
Entity Type:Organization
Organization Name:DOMINGUEZ PHARMACY LP
Other - Org Name:DOMINGUEZ PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-943-8188
Mailing Address - Street 1:1175 E ARROW HWY
Mailing Address - Street 2:SUITE K
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5525
Mailing Address - Country:US
Mailing Address - Phone:909-981-1009
Mailing Address - Fax:909-981-3612
Practice Address - Street 1:31739 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7818
Practice Address - Country:US
Practice Address - Phone:951-674-4600
Practice Address - Fax:951-674-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CA499143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336373646Medicaid
5634387OtherNCPDP PROVIDER IDENTIFICATION NUMBER