Healthcare Provider Details

I. General information

NPI: 1003943739
Provider Name (Legal Business Name): PUENTE HILLS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 S AZUSA AVE SUITE 101
HACIENDA HEIGHTS CA
91745-6813
US

IV. Provider business mailing address

1850 S AZUSA AVE SUITE 101
HACIENDA HEIGHTS CA
91745-6813
US

V. Phone/Fax

Practice location:
  • Phone: 626-912-3311
  • Fax:
Mailing address:
  • Phone: 626-912-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY35041
License Number StateCA

VIII. Authorized Official

Name: RAYMOND WONG
Title or Position: PHARMACIST
Credential: PHARM.D.
Phone: 626-912-3311