Healthcare Provider Details

I. General information

NPI: 1093569105
Provider Name (Legal Business Name): UNIVERSITY OF CALIFORNIA IRVINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19208 JAMBOREE ROAD BLDG 823, RM 2350
IRVINE CA
92612
US

IV. Provider business mailing address

1500 S DOUGLASS RD SUITE 200, RT 183
ANAHEIM CA
92806-6912
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5086
  • Fax:
Mailing address:
  • Phone: 714-509-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GINA CHURCHILL
Title or Position: REIMBURSEMENT DIRECTOR
Credential:
Phone: 714-509-6266