Basic Information
| Provider Information | |||||||||
| NPI: | 1457309577 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTINEZ VAMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94412 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441014412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023413020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10535 HOSPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | MATHER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956554200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075628202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2023822579 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 | 0575588 | 01 | CA | NCPDP# | OTHER |