Healthcare Provider Details

I. General information

NPI: 1730194366
Provider Name (Legal Business Name): CALIFORNIA STATE UNIVERSITY FULLERTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N STATE COLLEGE BLVD
FULLERTON CA
92831-3547
US

IV. Provider business mailing address

PO BOX 6830
FULLERTON CA
92834-6830
US

V. Phone/Fax

Practice location:
  • Phone: 714-278-2890
  • Fax: 714-278-5508
Mailing address:
  • Phone: 714-278-2890
  • Fax: 714-278-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHE19591
License Number StateCA

VIII. Authorized Official

Name: MS. KATHY J SPOTFORD
Title or Position: DIRECTOR
Credential: MBA
Phone: 657-278-2822