Provider Demographics
NPI:1699880625
Name:LOMA LINDA HEALTH PHARMACY
Entity type:Organization
Organization Name:LOMA LINDA HEALTH PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:909-796-3780
Mailing Address - Street 1:11382 MT. VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-796-3780
Mailing Address - Fax:909-796-5783
Practice Address - Street 1:11382 MT. VIEW AVE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-796-3780
Practice Address - Fax:909-796-5783
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOMA LINDA HEALTH PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 333600000X
CAPHY394773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA394770Medicaid
2094485OtherPK