Basic Information
Provider Information | |||||||||
NPI: | 1801226642 | ||||||||
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 AVENUE | ||||||||
Address2: | SUITE 107 | ||||||||
City: | GARDENA | ||||||||
State: | CA | ||||||||
PostalCode: | 902484411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104648241 | ||||||||
FaxNumber: | 3107710621 | ||||||||
Practice Location | |||||||||
Address1: | 8212 SANTA MONICA BLVD | ||||||||
Address2: |   | ||||||||
City: | WEST HOLLYWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 900465913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3236540907 | ||||||||
FaxNumber: | 3236546264 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2013 | ||||||||
LastUpdateDate: | 11/14/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REIS | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3238605200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | PHY48827 | CA | Y |   | Suppliers | Pharmacy |   |
No ID Information.