=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285736694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 E 21ST ST
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-882-3719
-----------------------------------------------------
Fax | 909-881-2390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 399 E HIGHLAND AVE SUITE 103
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-882-3719
-----------------------------------------------------
Fax | 909-881-2390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT BEEMAN
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 909-882-3719
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY11381
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------