MEDICARE: DETENTION'S FACILITY PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336I0012X	Institutional Pharmacy	BD7140128	CA

General Provider Information

NPI Number	:	1306057229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DETENTION'S FACILITY PHARMACY

Provider Business Mailing Address
First Line	:	8525 GIBBS DR STE 101
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1758
Country	:	US
Telephone Number	:	858-974-5977
Fax Number	:	858-974-5827

Provider Business Practice Location Address
First Line	:	8525 GIBBS DR STE 101
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1758
Country	:	US
Telephone Number	:	858-974-5977
Fax Number	:	858-974-5827

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. BRUCE LEICHT
Credential	:
Telephone Number	:	858-974-5962

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	08/22/2020

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