Healthcare Provider Details

I. General information

NPI: 1407877483
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF CA-UCSD AMBULATORY CARE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 LEWIS ST 2ND FLR
SAN DIEGO CA
92103-2108
US

IV. Provider business mailing address

200 W ARBOR DR MAIL CODE 8765
SAN DIEGO CA
92103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 619-471-9235
  • Fax: 619-471-9236
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 NumberPHE37896
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHE37896
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHE37896
License Number StateCA

VIII. Authorized Official

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