Healthcare Provider Details

I. General information

NPI: 1417306200
Provider Name (Legal Business Name): FAIRVIEW MTM PHARMA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 N FAIRVIEW ST
SANTA ANA CA
92703-1811
US

IV. Provider business mailing address

1002 N FAIRVIEW ST
SANTA ANA CA
92703-1811
US

V. Phone/Fax

Practice location:
  • Phone: 714-881-0012
  • Fax: 714-486-2378
Mailing address:
  • Phone: 714-881-0012
  • Fax: 714-881-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY54449
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENISE T. LE
Title or Position: PRESIDENT/CEO/PIC
Credential:
Phone: 714-881-0012