Basic Information
Provider Information | |||||||||
NPI: | 1225054000 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LONGS DRUG STORES CALIFORNIA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LONGS DRUG STORE #735/NETWORK PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | FILE 73241 | ||||||||
Address2: | P.O. BOX 60000 | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941600001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9252106659 | ||||||||
FaxNumber: | 9252106606 | ||||||||
Practice Location | |||||||||
Address1: | 760 WASHBURN AVE | ||||||||
Address2: | #2 | ||||||||
City: | CORONA | ||||||||
State: | CA | ||||||||
PostalCode: | 928823303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9517381669 | ||||||||
FaxNumber: | 9517381779 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 03/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALLIDAY | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGED CARE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9252106659 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PHY47568 | CA | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 5622332 | 01 | CA | NCPDP | OTHER | PHA475680 | 05 | CA |   | MEDICAID |