Basic Information
| Provider Information | |||||||||
| NPI: | 1750493672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL PHARMACEUTICAL SERVICES CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INFUSIONRX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6912 S QUENTIN ST STE 50 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801124531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202825325 | ||||||||
| FaxNumber: | 8776760493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1833 PORTOLA RD UNITS K & L | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930036435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059812500 | ||||||||
| FaxNumber: | 8059818447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | IRIYE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7202822377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERITA, INC. | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336H0001X | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5616632 | 01 | NCPDP | OTHER | 1750493672 | 05 | CA | MEDICAID |