Healthcare Provider Details

I. General information

NPI: 1508972456
Provider Name (Legal Business Name): PROVIDENCE HEALTH SYSTEM-SOUTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W 7TH ST
SAN PEDRO CA
90732-3505
US

IV. Provider business mailing address

1300 W 7TH ST
SAN PEDRO CA
90732-3505
US

V. Phone/Fax

Practice location:
  • Phone: 310-832-3311
  • Fax: 310-514-5462
Mailing address:
  • Phone: 310-514-5267
  • Fax: 310-514-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberHSP47226
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENTS
Credential:
Phone: 425-358-9786