Basic Information
| Provider Information | |||||||||
| NPI: | 1902167141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AIDS HEALTHCARE FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AHF PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19300 S HAMILTON AVE STE 110-111 | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902484400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238605241 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5700 HILLANDALE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300584104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708083705 | ||||||||
| FaxNumber: | 7708084432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2012 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARRUTHERS | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. MGR / CHIEF PHARM. OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3238605200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PHRE009841 | GA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2135406 | 01 | PK | OTHER | 003124620A | 05 | GA | MEDICAID |