Healthcare Provider Details

I. General information

NPI: 1316135569
Provider Name (Legal Business Name): FIDELIS HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 S BALDWIN AVE
ARCADIA CA
91007-7234
US

IV. Provider business mailing address

1002 S BALDWIN AVE
ARCADIA CA
91007-7234
US

V. Phone/Fax

Practice location:
  • Phone: 626-447-2138
  • Fax: 626-447-6433
Mailing address:
  • Phone: 626-447-2138
  • Fax: 626-447-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPHY52510
License Number StateCA

VIII. Authorized Official

Name: WAGNER A LEMUS
Title or Position: PRESIDENT
Credential:
Phone: 702-815-0800