Healthcare Provider Details

I. General information

NPI: 1003201328
Provider Name (Legal Business Name): PINE DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 S MAIN ST
SANTA ANA CA
92701-5716
US

IV. Provider business mailing address

618 S MAIN ST
SANTA ANA CA
92701-5716
US

V. Phone/Fax

Practice location:
  • Phone: 714-676-2078
  • Fax: 714-676-2079
Mailing address:
  • Phone: 714-676-2078
  • Fax: 714-839-5871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number53628
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN DANG
Title or Position: PHARMACY MANAGER
Credential:
Phone: 714-839-1267