Basic Information
| Provider Information | |||||||||
| NPI: | 1316322647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF CALIFORNIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 21633 AVENUE 24 | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936109650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596656100 | ||||||||
| FaxNumber: | 5596656586 | ||||||||
| Practice Location | |||||||||
| Address1: | 21633 AVENUE 24 | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936109650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596656100 | ||||||||
| FaxNumber: | 5596656586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | FRANCISCO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST II | ||||||||
| AuthorizedOfficialTelephone: | 5596656100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | LCF 45081 | CA | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 261QP2400X | LCF 45081 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Prison Health |
No ID Information.