Basic Information
Provider Information | |||||||||
NPI: | 1871551002 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST LOS ANGELES VAMC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SEPULVEDA VA CBOC PHARMACY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 94424 | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441014424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023413152 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 16111 PLUMMER ST | ||||||||
Address2: |   | ||||||||
City: | SEPULVEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 913432036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188959341 | ||||||||
FaxNumber: | 8188959530 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 04/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | ERIN | ||||||||
AuthorizedOfficialMiddleName: | DENISE | ||||||||
AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
AuthorizedOfficialTelephone: | 2023822579 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332100000X |   |   | Y |   | Suppliers | Department of Veterans Affairs (VA) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 0514237 | 01 | CA | NCPDP# | OTHER |