Basic Information
| Provider Information | |||||||||
| NPI: | 1225075971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHARP CORONADO HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8695 SPECTRUM CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584993025 | ||||||||
| FaxNumber: | 8584993020 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PROSPECT PL | ||||||||
| Address2: | |||||||||
| City: | CORONADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921181943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195223700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6195223700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336I0012X | HSP22448 | CA | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PHB155870 | 05 | CA | MEDICAID |