Provider Demographics
NPI:1083617740
Name:LA QUINTA PHARMACY
Entity type:Organization
Organization Name:LA QUINTA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANKIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-777-9902
Mailing Address - Street 1:78150 CALLE TAMPICO
Mailing Address - Street 2:STE 103
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78150 CALLE TAMPICO
Practice Address - Street 2:STE 103
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2907
Practice Address - Country:US
Practice Address - Phone:760-777-9902
Practice Address - Fax:760-777-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X
CA46507333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5600918OtherOTHER ID NUMBER-COMMERCIAL NUMBER