Basic Information
| Provider Information | |||||||||
| NPI: | 1871530238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP CHULA VISTA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHARP CHULA VISTA MEDICAL CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8695 SPECTRUM CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584993025 | ||||||||
| FaxNumber: | 8584994738 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 MEDICAL CENTER CT | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919116617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194825342 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 08/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | VELEZ | ||||||||
| AuthorizedOfficialFirstName: | PABLO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6195023031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | HSP18447 | CA | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PHB184470 | 05 | CA | MEDICAID |