Provider Demographics
NPI:1992162077
Name:PHARMACY MART INC
Entity type:Organization
Organization Name:PHARMACY MART INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-868-2800
Mailing Address - Street 1:4050 PHELAN RD
Mailing Address - Street 2:STE 8
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-4454
Mailing Address - Country:US
Mailing Address - Phone:760-868-2800
Mailing Address - Fax:760-868-5852
Practice Address - Street 1:4050 PHELAN RD STE 8
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-4454
Practice Address - Country:US
Practice Address - Phone:760-868-2800
Practice Address - Fax:760-868-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X, 333600000X, 3336C0002X
CAPHY546043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157699OtherPK