=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407877483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGENTS OF THE UNIVERSITY OF CA-UCSD AMBULATORY CARE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 06/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 LEWIS ST 2ND FLR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-471-9235
-----------------------------------------------------
Fax | 619-471-9236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 W ARBOR DR MAIL CODE 8765
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-543-6194
-----------------------------------------------------
Fax | 619-543-5829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR UCSD AMCARE PHARMACY
-----------------------------------------------------
Name | MR. GARY HAGNEY
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 619-543-6194
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | PHE37896
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHE37896
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHE37896
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------