Provider Demographics
NPI:1306939749
Name:BUNNAUN UCH
Entity type:Organization
Organization Name:BUNNAUN UCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:BUNNAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:UCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-888-2099
Mailing Address - Street 1:4555 N PERSHING AVE
Mailing Address - Street 2:STE 7
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6740
Mailing Address - Country:US
Mailing Address - Phone:209-473-4706
Mailing Address - Fax:209-473-7377
Practice Address - Street 1:4555 N PERSHING AVE
Practice Address - Street 2:STE 7
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6740
Practice Address - Country:US
Practice Address - Phone:209-888-2099
Practice Address - Fax:209-888-2105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
CAPHY532623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151610OtherPK
CAPHA532620Medicaid