Provider Demographics
NPI:1457754731
Name:IMGRX HEALSDBURG INC
Entity Type:Organization
Organization Name:IMGRX HEALSDBURG INC
Other - Org Name:AMC COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-749-4764
Mailing Address - Street 1:ATTN: CHC PHARMACY DEPT.
Mailing Address - Street 2:13651 DUBLIN CT.
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4317
Mailing Address - Country:US
Mailing Address - Phone:281-749-4000
Mailing Address - Fax:614-652-0326
Practice Address - Street 1:1381 UNIVERSITY ST STE A
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3314
Practice Address - Country:US
Practice Address - Phone:707-385-2336
Practice Address - Fax:707-431-8331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMGRX HEALSDBURG INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-01
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA525023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152667OtherPK