Basic Information
| Provider Information | |||||||||
| NPI: | 1467536326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN YSIDRO HEALTH PHARMACY-SAN YSIDRO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PRECISION PARK LN | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921731345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | 6194282625 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 BEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN YSIDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | 6192056373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATTSON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6196624100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | DREPHA382000 | 01 | CA | FPACT | OTHER |