Basic Information
Provider Information | |||||||||
NPI: | 1588087308 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AIDS HEALTHCARE FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AHF PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19300 S HAMILTON AVE STE 110-111 | ||||||||
Address2: |   | ||||||||
City: | GARDENA | ||||||||
State: | CA | ||||||||
PostalCode: | 902484400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238605241 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 700 SE 3RD AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333161154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9547614531 | ||||||||
FaxNumber: | 9547614539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2014 | ||||||||
LastUpdateDate: | 02/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARRUTHERS | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR. MANAGER NATIONAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3238605300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | PH27373 | FL | N |   | Suppliers | Pharmacy |   | 3336C0003X | 032721 | NY | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | PHNR.FO.60576925 | WA | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | NRP022453200-03 | OH | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | PHY007002-NR | LA | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | NRX0000479 | DC | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2144065 | 01 |   | PK | OTHER | 010793700 | 05 | FL |   | MEDICAID |