Provider Demographics
NPI:1447653787
Name:ALTAMED HEALTH SERVICE CORPOTATION
Entity type:Organization
Organization Name:ALTAMED HEALTH SERVICE CORPOTATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CASTULO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-430-3286
Mailing Address - Street 1:1855 N FAIR OAKS AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1620
Mailing Address - Country:US
Mailing Address - Phone:888-499-9303
Mailing Address - Fax:626-993-1222
Practice Address - Street 1:1855 N FAIR OAKS AVE
Practice Address - Street 2:STE 100
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1620
Practice Address - Country:US
Practice Address - Phone:888-499-9303
Practice Address - Fax:626-398-5848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA516913336C0003X, 3336C0003X
3336C0002X, 3336M0002X, 3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166536OtherPK
CAW14338Medicaid
2166536OtherPK