Basic Information
| Provider Information | |||||||||
| NPI: | 1972551687 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIALTY PHARMACIES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CASTRO STREET PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 191 GOLDEN GATE AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941023809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152550516 | ||||||||
| FaxNumber: | 4152550937 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 GOLDEN GATE AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941023809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152550516 | ||||||||
| FaxNumber: | 4152550937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FICHERA | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5082971018 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | PHY 50167 | CA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0585464 | 01 | NCPDP PROVIDER ID | OTHER | PHA 50167 | 05 | CA | MEDICAID | FC2037720 | 01 | CA | DEA | OTHER | PHY 50167 | 01 | CA | STATE LICENSE | OTHER |