=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043527534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YDS PHARMACY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 10/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12370 HESPERIA RD STE 7
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-4787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-843-7200
-----------------------------------------------------
Fax | 760-843-7360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12370 HESPERIA RD SUITE 7
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-7719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-843-7200
-----------------------------------------------------
Fax | 760-843-7360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRANDON HUYNH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-843-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY50425
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------