Basic Information
| Provider Information | |||||||||
| NPI: | 1528009602 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHARP REES-STEALY PHARMACY #3 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8695 SPECTRUM CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584993025 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16899 W BERNARDO DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921271603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585212290 | ||||||||
| FaxNumber: | 8585212004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HROUNTAS | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO SHARP REES-STEALY | ||||||||
| AuthorizedOfficialTelephone: | 8582626003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARP HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PHY55457 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | FLU011C | 01 | CA | MEDICARE | OTHER | 1999407 | 01 | PK | OTHER | PHA451060 | 05 | CA | MEDICAID |