Provider Demographics
NPI:1841302775
Name:MESA PHARMACY INC
Entity type:Organization
Organization Name:MESA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-354-7578
Mailing Address - Street 1:1900 ROYALTY DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3032
Mailing Address - Country:US
Mailing Address - Phone:909-623-8600
Mailing Address - Fax:909-623-8686
Practice Address - Street 1:1900 ROYALTY DR STE 190
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3050
Practice Address - Country:US
Practice Address - Phone:909-623-8600
Practice Address - Fax:909-623-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5616935OtherNCPDP PROVIDER IDENTIFICATION NUMBER