Healthcare Provider Details

I. General information

NPI: 1477734507
Provider Name (Legal Business Name): SPECIALTY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 POMONA BLVD STE B
POMONA CA
91768-3272
US

IV. Provider business mailing address

2680 POMONA BLVD STE B
POMONA CA
91768-3272
US

V. Phone/Fax

Practice location:
  • Phone: 626-688-5326
  • Fax: 626-599-2025
Mailing address:
  • Phone: 626-688-5326
  • Fax: 800-619-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number25251
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY42098
License Number StateCA

VIII. Authorized Official

Name: DOUG D SULLIVAN
Title or Position: OWNER
Credential:
Phone: 626-688-5326