Provider Demographics
NPI:1285728683
Name:DOMINGUEZ PHARMACY LP
Entity type:Organization
Organization Name:DOMINGUEZ PHARMACY LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:951-707-5095
Mailing Address - Street 1:949 TALCEY TER
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-7517
Mailing Address - Country:US
Mailing Address - Phone:951-707-5095
Mailing Address - Fax:951-780-1685
Practice Address - Street 1:1175 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5525
Practice Address - Country:US
Practice Address - Phone:909-981-1009
Practice Address - Fax:909-981-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA499303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285728683Medicaid
2120719OtherPK
6064880008Medicare NSC