Healthcare Provider Details

I. General information

NPI: 1790955987
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF CALIFORNIA-UCSD AMBULATORY CARE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8939 VILLA LA JOLLA DR STE 129
LA JOLLA CA
92037-1732
US

IV. Provider business mailing address

200 W ARBOR DR MAIL CODE 8765
SAN DIEGO CA
92103-9001
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-2220
  • Fax: 858-657-2228
Mailing address:
  • Phone: 619-543-6194
  • Fax: 619-543-5829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHE48990
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHE48990
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHE48990
License Number StateCA

VIII. Authorized Official

Name: MR. GARY HAGNEY
Title or Position: DIRECTOR UCSD AMCARE PHARMACY
Credential: RPH
Phone: 619-543-6194