Provider Demographics
NPI:1174618862
Name:SEVENTH-DAY ADVENTISTS LOMA LINDA UNIVERSITY MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:SEVENTH-DAY ADVENTISTS LOMA LINDA UNIVERSITY MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:909-558-4566
Mailing Address - Street 1:11161 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2824
Mailing Address - Country:US
Mailing Address - Phone:909-558-4566
Mailing Address - Fax:909-558-4586
Practice Address - Street 1:11161 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2824
Practice Address - Country:US
Practice Address - Phone:909-558-4566
Practice Address - Fax:909-558-4586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY35986333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-64434OtherNAPB
CAPHA359860Medicaid