Basic Information
| Provider Information | |||||||||
| NPI: | 1013024132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMGRX SJ VALLEY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UNITED HEALTH CENTERS PARLIER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | ATTN: CHC RETAIL PHARMACY DEPT. 13651 DUBLIN CT | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817494000 | ||||||||
| FaxNumber: | 6146520326 | ||||||||
| Practice Location | |||||||||
| Address1: | 429 E MANNING AVE BLDG 1 | ||||||||
| Address2: | |||||||||
| City: | PARLIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936482668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596463561 | ||||||||
| FaxNumber: | 5596466916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2817494764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IMGRX SJ VALLEY, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 54519 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PHA198030 | 05 | CA | MEDICAID |