Provider Demographics
NPI:1588768535
Name:LOMA LINDA UNIVERSITY COMMUNITY PHARMACY
Entity type:Organization
Organization Name:LOMA LINDA UNIVERSITY COMMUNITY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-558-6447
Mailing Address - Street 1:25455 BARTON RD
Mailing Address - Street 2:STE 111 A
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3128
Mailing Address - Country:US
Mailing Address - Phone:909-558-6447
Mailing Address - Fax:909-558-6155
Practice Address - Street 1:25455 BARTON RD
Practice Address - Street 2:STE 111 A
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3128
Practice Address - Country:US
Practice Address - Phone:909-558-6447
Practice Address - Fax:909-558-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY445263336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997126OtherPK
CAPHA445260Medicaid