Basic Information
| Provider Information | |||||||||
| NPI: | 1275728198 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEDICATION MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 35325 DATE PALM DR STE 239 | ||||||||
| Address2: | |||||||||
| City: | CATHEDRAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922347015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609696560 | ||||||||
| FaxNumber: | 7603282230 | ||||||||
| Practice Location | |||||||||
| Address1: | 35325 DATE PALM DR STE 239 | ||||||||
| Address2: | |||||||||
| City: | CATHEDRAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922347015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609696560 | ||||||||
| FaxNumber: | 7603282230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRANDON | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7603204122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPCS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.