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General NPI Number Information
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NPI Number | 1609904119
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Entity Type | Organization
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Legal Business Name | IRVINE SAND CANYON PHARMACY INC
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 72624 EL PASEO SUITE A1
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City | PALM DESERT
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State | CA
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Zip | 92260-3309
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Country | US
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Telephone | 760-341-3984
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Fax | 760-341-4954
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Provider Business Mailing Address
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Address Line | 8 SCARBOROUGH WAY ROOM 92270
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-1624
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Country | US
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Telephone | 310-880-2537
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MORT FARINA
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Credential | R.PH.
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Telephone | 310-880-2537
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 99148
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License Number State | CA
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Legacy Identifiers
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Identifier #1
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Identifier Code | 44047
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Identifier Type | OTHER
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Identifier State | CA
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Identifier Issuer | PHARMACY LICENSE
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 44047
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Identifier Type | OTHER
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Identifier State | CA
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Identifier Issuer | PHARMACY LICENSE
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