Healthcare Provider Details

I. General information

NPI: 1457754731
Provider Name (Legal Business Name): IMGRX HEALSDBURG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 09/06/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 UNIVERSITY ST STE A
HEALDSBURG CA
95448-3314
US

IV. Provider business mailing address

ATTN: CHC PHARMACY DEPT. 13651 DUBLIN CT.
STAFFORD TX
77477-4317
US

V. Phone/Fax

Practice location:
  • Phone: 707-385-2336
  • Fax: 707-431-8331
Mailing address:
  • Phone: 281-749-4000
  • Fax: 614-652-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number52502
License Number StateCA

VIII. Authorized Official

Name: MR. MICHAEL BROWN
Title or Position: VICE PRESIDENT, MANAGED SERVICES
Credential:
Phone: 281-749-4764