Basic Information
Provider Information | |||||||||
NPI: | 1932468725 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AIDS HEALTHCARE FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOMS PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6255 W. SUNSET BLVD., 21ST FLOOR | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 90028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238605281 | ||||||||
FaxNumber: | 3238605315 | ||||||||
Practice Location | |||||||||
Address1: | 75 AMORY STREET | ||||||||
Address2: |   | ||||||||
City: | ROXBURY | ||||||||
State: | MA | ||||||||
PostalCode: | 02119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177083922 | ||||||||
FaxNumber: | 6175220631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2012 | ||||||||
LastUpdateDate: | 05/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARRUTHERS | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | SCOTT | ||||||||
AuthorizedOfficialTitleorPosition: | NATIONAL DIRECTOR OF PHARMACY-SRMGR | ||||||||
AuthorizedOfficialTelephone: | 3238605266 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.