Provider Demographics
NPI:1871967315
Name:ABC PHARMACY
Entity type:Organization
Organization Name:ABC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:909-285-1118
Mailing Address - Street 1:7974 HAVEN AVE
Mailing Address - Street 2:120
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3052
Mailing Address - Country:US
Mailing Address - Phone:877-222-4598
Mailing Address - Fax:
Practice Address - Street 1:7974 HAVEN AVE
Practice Address - Street 2:120
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3052
Practice Address - Country:US
Practice Address - Phone:877-222-4598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA636483336M0002X
AZ0064493336M0002X
NV034143336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245676618Medicaid