Basic Information
| Provider Information | |||||||||
| NPI: | 1457532590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIALTY PHARMACIES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | 2ND STREET PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 MELVILLE PARK RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117473109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315476531 | ||||||||
| FaxNumber: | 6315476532 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 2ND ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946073839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108350774 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FICHERA | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5082971018 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLION HEALTHCARE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | F91809788 | 01 | CA | DEA | OTHER | 5628803 | 01 | CA | NCPDP | OTHER | PHY 50166 | 01 | CA | STATE LICENSE | OTHER | PHA 50166 | 05 | CA | MEDICAID |