Basic Information
| Provider Information | |||||||||
| NPI: | 1649600487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AIDS HEALTHCARE FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AHF PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19300 S. HAMILTON AVENUE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902484411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104648241 | ||||||||
| FaxNumber: | 3107710621 | ||||||||
| Practice Location | |||||||||
| Address1: | 3940 FOURTH AVENUE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921037193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195749700 | ||||||||
| FaxNumber: | 6195749701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2013 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | REIS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3238605200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | PHY51043 | CA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3065340 | 05 | CA | MEDICAID |