Provider Demographics
NPI:1316968399
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR UCSD AMCARE PHARM
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-543-6194
Mailing Address - Street 1:200 W ARBOR DR
Mailing Address - Street 2:MC 8765
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9000
Mailing Address - Country:US
Mailing Address - Phone:619-543-6194
Mailing Address - Fax:
Practice Address - Street 1:4168 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2030
Practice Address - Country:US
Practice Address - Phone:619-543-5934
Practice Address - Fax:619-543-6784
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-22
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE378953336C0002X, 3336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0546450OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHB378950Medicaid
CA0411500005Medicare NSC