Provider Demographics
NPI:1700956885
Name:DIVYA RX SERVICES
Entity Type:Organization
Organization Name:DIVYA RX SERVICES
Other - Org Name:HERITAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:760-416-7999
Mailing Address - Street 1:275 N EL CIELO RD
Mailing Address - Street 2:D405
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-6972
Mailing Address - Country:US
Mailing Address - Phone:760-416-7999
Mailing Address - Fax:760-416-7688
Practice Address - Street 1:275 N EL CIELO RD
Practice Address - Street 2:D405
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-6972
Practice Address - Country:US
Practice Address - Phone:760-416-7999
Practice Address - Fax:760-416-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY554283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996630OtherPK
CAPHA443070Medicaid