Healthcare Provider Details

I. General information

NPI: 1043445208
Provider Name (Legal Business Name): SAI BEAR CREEK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24046 CLINTON KEITH RD SUITE 107
WILDOMAR CA
92595
US

IV. Provider business mailing address

24046 CLINTON KEITH RD SUITE 107
WILDOMAR CA
92595
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-4880
  • Fax: 951-698-4392
Mailing address:
  • Phone: 951-677-4880
  • Fax: 951-698-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50678
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. SAISATISH GUNDA
Title or Position: MANAGING MEMBER
Credential:
Phone: 951-677-4880