Basic Information
| Provider Information | |||||||||
| NPI: | 1023027620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGS DRUG STORE #733/NETWORK PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 N CIVIC DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945963815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252106660 | ||||||||
| FaxNumber: | 9252106222 | ||||||||
| Practice Location | |||||||||
| Address1: | 12276 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609628007 | ||||||||
| FaxNumber: | 7609628011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CUETO | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9252106660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PHY47581 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.