Provider Demographics
NPI:1982785671
Name:EL TEJON DRUG CO.
Entity Type:Organization
Organization Name:EL TEJON DRUG CO.
Other - Org Name:EL TEJON DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:661-399-2901
Mailing Address - Street 1:PO BOX 11270
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93389-1270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2819 N CHESTER AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-1587
Practice Address - Country:US
Practice Address - Phone:661-399-2901
Practice Address - Fax:661-399-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY459653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1982785671Medicaid
2028512OtherPK
CAPHA459650Medicaid