Basic Information
| Provider Information | |||||||||
| NPI: | 1770743007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVRX PHARMACY SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MED SPECIALTIES COMPOUNDING PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4862 OLINDA ST | ||||||||
| Address2: | |||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928863419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145722272 | ||||||||
| FaxNumber: | 7145722277 | ||||||||
| Practice Location | |||||||||
| Address1: | 4862 OLINDA ST | ||||||||
| Address2: | |||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928863419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145722272 | ||||||||
| FaxNumber: | 7145722277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ANTONIO | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 7145722272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM. D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | RPH50523 | CA | Y | Suppliers | Pharmacy |
No ID Information.