Basic Information
| Provider Information | |||||||||
| NPI: | 1366400244 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRESNO VAMC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | FRESNO VAMC PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94410 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441014410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023413020 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2615 E CLINTON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592256100 | ||||||||
| FaxNumber: | 5592416496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2023822579 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332100000X | Y | Suppliers | Department of Veterans Affairs (VA) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0550207 | 01 | CA | NCPDP# | OTHER | AV6638297 | 01 | CA | DEA# | OTHER |