MEDICARE: CHINO HILLS MED-PLAZA PHARMACY INC

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	3336C0003X	Community/Retail Pharmacy	52534	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2149787	OTHER		PK

General Provider Information

NPI Number	:	1740679901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHINO HILLS MED-PLAZA PHARMACY INC

Provider Business Mailing Address
First Line	:	3110 CHINO AVE
Second Line	:	SUITE 100
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-1211
Country	:	US
Telephone Number	:	909-465-6562
Fax Number	:	909-465-9260

Provider Business Practice Location Address
First Line	:	3110 CHINO AVE STE 100
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-1294
Country	:	US
Telephone Number	:	909-465-6562
Fax Number	:	909-465-9260

Authorized Official
Title or Position	:	PRESIDENT/PIC
Name	:	RAANA SIDKY
Credential	:
Telephone Number	:	909-465-6562

Provider Enumeration Date	:	01/12/2015
Last Update Date	:	02/27/2015

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