Provider Demographics
NPI:1205997947
Name:HESPERIA LA SALLE PHARMACY
Entity type:Organization
Organization Name:HESPERIA LA SALLE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER RPH
Authorized Official - Prefix:MRS
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-956-2270
Mailing Address - Street 1:16455 MAIN ST
Mailing Address - Street 2:#8
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345
Mailing Address - Country:US
Mailing Address - Phone:760-956-2270
Mailing Address - Fax:760-956-7093
Practice Address - Street 1:16455 MAIN ST
Practice Address - Street 2:#8
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345
Practice Address - Country:US
Practice Address - Phone:760-956-2270
Practice Address - Fax:760-956-7093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 43984333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA439850Medicaid
CAPHA439850Medicaid