Healthcare Provider Details

I. General information

NPI: 1699227983
Provider Name (Legal Business Name): LANDMARK PHARMA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 ALTA AVE STE 100
UPLAND CA
91786-2804
US

IV. Provider business mailing address

1113 ALTA AVE STE 100
UPLAND CA
91786-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-360-8352
  • Fax: 909-360-8372
Mailing address:
  • Phone: 909-360-8352
  • Fax: 909-360-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
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 Number55396
License Number StateCA

VIII. Authorized Official

Name: JINESH PATEL
Title or Position: PRESIDENT, AO
Credential:
Phone: 714-270-7432