Basic Information
| Provider Information | |||||||||
| NPI: | 1407898265 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER CENTRAL VALLEY HOSPITALS | ||||||||
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| OtherOrganizationName: | MEMORIAL MEDICAL CENTER OPT PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 740152 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553981633 | ||||||||
| FaxNumber: | 2095697362 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 COFFEE ROAD | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095697642 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 12/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | TRENT | ||||||||
| AuthorizedOfficialTitleorPosition: | VP SHARED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9162978555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | HSP37596 | CA | N | Agencies | Home Infusion | 332BP3500X | HSP37596 | CA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336C0003X | HSP37596 | CA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336H0001X | HSP37596 | CA | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 282N00000X | 030000061 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 050557 | 01 | BLUE CROSS | OTHER | PHB375960 | 05 | CA | MEDICAID | 0538009 | 01 | CA | NABP | OTHER | 0538009 | 01 | CA | NCPDP | OTHER |