Healthcare Provider Details

I. General information

NPI: 1093870412
Provider Name (Legal Business Name): INNOVATIVE INTRATHECAL SOLUTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41538 EASTMAN DR
MURRIETA CA
92562-8007
US

IV. Provider business mailing address

41538 EASTMAN DR
MURRIETA CA
92562-8007
US

V. Phone/Fax

Practice location:
  • Phone: 951-304-9530
  • Fax: 951-304-9540
Mailing address:
  • Phone: 951-304-9530
  • Fax: 951-304-9540

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 NumberPHY49935
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY BARRACK
Title or Position: PRESIDENT
Credential: RPH
Phone: 951-304-9530