Basic Information
Provider Information | |||||||||
NPI: | 1346401015 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LONGS DRUG STORES CALIFORNIA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LONGS PHARMACY 300 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 141 N CIVIC DR | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945963815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9252106659 | ||||||||
FaxNumber: | 9252106606 | ||||||||
Practice Location | |||||||||
Address1: | 925 CALIFORNIA AVE | ||||||||
Address2: |   | ||||||||
City: | WAHIAWA | ||||||||
State: | HI | ||||||||
PostalCode: | 967862123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086217772 | ||||||||
FaxNumber: | 8086211485 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2008 | ||||||||
LastUpdateDate: | 06/24/2008 | ||||||||
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 | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.