=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861297178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EL MIRADOR MEDICAL PLAZA PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21634 RETREAT PKWY STE 101
-----------------------------------------------------
City | TEMESCAL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92883-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-963-3330
-----------------------------------------------------
Fax | 951-963-3331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1180 N INDIAN CANYON DR STE E140
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-4883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-323-1001
-----------------------------------------------------
Fax | 760-323-1144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RAMESH UPADHYAYULA
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 760-323-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------