=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548778723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SAMARITAN PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2018
-----------------------------------------------------
Last Update Date | 05/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8137 MALACHITE AVE STE A
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-774-1115
-----------------------------------------------------
Fax | 909-774-1118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8137 MALACHITE AVE STE A
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-774-1115
-----------------------------------------------------
Fax | 909-774-1118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MYLENE BUNAGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-774-1115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 56061
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------