Provider Demographics
NPI:1538231311
Name:GOOD SAMARITAN PHARMACY INC
Entity type:Organization
Organization Name:GOOD SAMARITAN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-305-0358
Mailing Address - Street 1:629 W COVINA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2913
Mailing Address - Country:US
Mailing Address - Phone:909-305-0358
Mailing Address - Fax:909-394-5649
Practice Address - Street 1:629 W COVINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2913
Practice Address - Country:US
Practice Address - Phone:909-305-0358
Practice Address - Fax:909-394-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
CAPHY556283336L0003X
CA398443336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169225OtherPK
CAPHA398440Medicaid
CAPHA398440Medicaid