Healthcare Provider Details

I. General information

NPI: 1497891766
Provider Name (Legal Business Name): TUSTIN COMMUNITY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17821 SANTIAGO BLVD
VILLA PARK CA
92861-4133
US

IV. Provider business mailing address

17821 SANTIAGO BLVD
VILLA PARK CA
92861-4133
US

V. Phone/Fax

Practice location:
  • Phone: 714-998-3030
  • Fax: 714-998-6060
Mailing address:
  • Phone: 714-998-3030
  • Fax: 714-998-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY46551
License Number StateCA

VIII. Authorized Official

Name: DR. ADAM BOLLENBACH
Title or Position: PHARMACIST-IN-CHARGE, VICE PRES.
Credential: PHARM.D.
Phone: 714-998-3030