MEDICARE: FOOTHILL 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	3336L0003X	Long Term Care Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY45239	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0538845	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1982615514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHILL PHARMACY

Provider Business Mailing Address
First Line	:	1850 N RIVERSIDE AVE
Second Line	:	SUITE 170
City	:	RIALTO
State	:	CA
Zip	:	92376-8071
Country	:	US
Telephone Number	:	909-874-2385
Fax Number	:	909-874-2428

Provider Business Practice Location Address
First Line	:	1850 N RIVERSIDE AVE
Second Line	:	SUITE 170
City	:	RIALTO
State	:	CA
Zip	:	92376-8071
Country	:	US
Telephone Number	:	909-874-2385
Fax Number	:	909-874-2428

Authorized Official
Title or Position	:	OWNER AND PHARMACIST
Name	:	ROBERT OLIVA
Credential	:
Telephone Number	:	909-874-2385

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	02/22/2011

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Directions to “FOOTHILL PHARMACY ” Practice Location

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