Basic Information
| Provider Information | |||||||||
| NPI: | 1568004174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY-STATE PRISON | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 900 QUEBEC AVE | ||||||||
| Address2: | |||||||||
| City: | CORCORAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932129715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599927100 | ||||||||
| FaxNumber: | 5599927201 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 QUEBEC AVE | ||||||||
| Address2: | |||||||||
| City: | CORCORAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932129715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599927100 | ||||||||
| FaxNumber: | 5599927201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2019 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROSENBLATT | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | KARL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST IN CHARGE | ||||||||
| AuthorizedOfficialTelephone: | 5599927100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | LCF43147 | 05 | CA | MEDICAID |