=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750491577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRING VALLEY LAKE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 01/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11919 HESPERIA RD STE C
-----------------------------------------------------
City | HESPERIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92345-2158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-244-3777
-----------------------------------------------------
Fax | 760-242-8617
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9778 SVL BOX
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-5142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-244-3777
-----------------------------------------------------
Fax | 760-244-2845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PIC
-----------------------------------------------------
Name | MR. RAAFAT FAYEZ ATTIA
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 760-244-3777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY51251
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------