Provider Demographics
NPI:1487722385
Name:FOOD4LESS OF SOUTHERN CALIFORNIA INC
Entity type:Organization
Organization Name:FOOD4LESS OF SOUTHERN CALIFORNIA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY ECOMMERCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-387-7113
Mailing Address - Street 1:3013 W CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-0598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3013 W CRAIG RD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-0598
Practice Address - Country:US
Practice Address - Phone:702-648-1608
Practice Address - Fax:702-648-4730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NVPH017663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002802495Medicaid
2988597OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3953350107Medicare NSC
NV002802495Medicaid