=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952548257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY PRACTICE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2009
-----------------------------------------------------
Last Update Date | 10/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 E 2ND ST HPC 133
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91766-1854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-706-3528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 E 2ND ST HPC 133
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91766-1854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-706-3528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT PROFESSOR OF PHARMACY
-----------------------------------------------------
Name | PROF. ROGER KLOTZ
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 909-469-5498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 38533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------