Provider Demographics
NPI:1669513529
Name:SAN ANTONIO INFUSION PHARMACY
Entity type:Organization
Organization Name:SAN ANTONIO INFUSION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHAM OPR
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCORSATTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-984-7132
Mailing Address - Street 1:105 W B ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 W B ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3502
Practice Address - Country:US
Practice Address - Phone:909-988-0591
Practice Address - Fax:909-988-0891
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEMMEL PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X
CAPHY488663336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0537247OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0537247OtherOTHER ID NUMBER
CA1669513529Medicaid
0537247OtherOTHER ID NUMBER-COMMERCIAL NUMBER