Provider Demographics
NPI:1801996855
Name:PROMISE HEALTH INC
Entity type:Organization
Organization Name:PROMISE HEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BHAVIK
Authorized Official - Middle Name:RAVJIBHAI
Authorized Official - Last Name:NASHIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-990-3000
Mailing Address - Street 1:18671 VALLEY BLVD UNIT B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-1831
Mailing Address - Country:US
Mailing Address - Phone:909-990-3000
Mailing Address - Fax:909-990-3003
Practice Address - Street 1:18671 VALLEY BLVD UNIT B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-1831
Practice Address - Country:US
Practice Address - Phone:909-990-3000
Practice Address - Fax:909-990-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 333600000X, 3336C0004X, 3336L0003X, 3336C0003X, 3336C0004X, 3336L0003X, 3336M0002X, 3336M0003X, 3336S0011X
CAPHY538283336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57338OtherBOARD OF PHARMACY LICENSE NUMBER
CA0534784OtherNCPDP
CAPHA176540Medicaid