Basic Information
| Provider Information | |||||||||
| NPI: | 1376190876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORRECTIONS AND REHABILITATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CORCORAN STATE PRISON HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 KING AVENUE | ||||||||
| Address2: | |||||||||
| City: | CORCORAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599928800 | ||||||||
| FaxNumber: | 5599927381 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 KING AVENUE | ||||||||
| Address2: | |||||||||
| City: | CORCORAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599928800 | ||||||||
| FaxNumber: | 5599927381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THARRATT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | STATEWIDE CHIEF MEDICAL EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 9166919913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORRECTIONS AND REHABILITATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | BC3615222 | 01 | CA | CORCORAN STATE PRISON HOSPITAL PHARMACY | OTHER |