Healthcare Provider Details

I. General information

NPI: 1235208570
Provider Name (Legal Business Name): PACIFIC PHARMACY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 E ALVARADO ST
FALLBROOK CA
92028-2966
US

IV. Provider business mailing address

1010 W LA VETA AVE SUITE 130
ORANGE CA
92868-4300
US

V. Phone/Fax

Practice location:
  • Phone: 760-728-1607
  • Fax: 760-728-2398
Mailing address:
  • Phone: 949-215-5522
  • Fax: 949-215-8988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY49043
License Number StateCA

VIII. Authorized Official

Name: JAN BALTHASAR
Title or Position: CEO
Credential:
Phone: 949-215-5522