Provider Demographics
NPI:1679081442
Name:PORTERVILLE PHARMACY INC
Entity type:Organization
Organization Name:PORTERVILLE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ADLY
Authorized Official - Last Name:MIKHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-750-9050
Mailing Address - Street 1:1270 W HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1455
Mailing Address - Country:US
Mailing Address - Phone:559-793-4410
Mailing Address - Fax:559-782-9091
Practice Address - Street 1:1270 W HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1455
Practice Address - Country:US
Practice Address - Phone:559-793-4410
Practice Address - Fax:559-782-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA558923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy