Basic Information
| Provider Information | |||||||||
| NPI: | 1750581526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGS DRUG STORES CALIFORNIA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LONGS DRUG STORE #380 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 4-831 KUHIO HWY | ||||||||
| Address2: | STE 500 | ||||||||
| City: | KAPAA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967461579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088224918 | ||||||||
| FaxNumber: | 8088210291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | HALLIDAY | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9252106659 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 562050 | HI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1203304 | 01 | HI | OTHER ID | OTHER | 08258701 | 05 | HI | MEDICAID |