Healthcare Provider Details

I. General information

NPI: 1720313257
Provider Name (Legal Business Name): C&A MEDICAL 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22642 LAMBERT ST STE 404
LAKE FOREST CA
92630-1645
US

IV. Provider business mailing address

22642 LAMBERT ST SUITE 404
LAKE FOREST CA
92630-1610
US

V. Phone/Fax

Practice location:
  • Phone: 949-347-8881
  • Fax: 949-347-8886
Mailing address:
  • Phone: 949-347-8881
  • Fax: 949-347-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number49911
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARYAM SHARAFSALEH
Title or Position: PRESIDENT
Credential:
Phone: 760-212-2761