Basic Information
| Provider Information | |||||||||
| NPI: | 1093057598 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AIDS HEALTH FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19300 S. HAMILTON AVENUE | ||||||||
| Address2: | STE 170 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107710619 | ||||||||
| FaxNumber: | 3107710621 | ||||||||
| Practice Location | |||||||||
| Address1: | 19300 S. HAMILTON AVE. | ||||||||
| Address2: | STE 170 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107710619 | ||||||||
| FaxNumber: | 3107710621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | MIMS | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 3107710619 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
No ID Information.