Basic Information
| Provider Information | |||||||||
| NPI: | 1912922055 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGS DRUG STORE #366 | ||||||||
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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: | 614 PALOMAR ST | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919117133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194091303 | ||||||||
| FaxNumber: | 6194091307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| 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 | PHY 48185 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.