1558304808 NPI number — LONGS DRUG STORES CALIFORNIA INC

Table of content: (NPI 1558304808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558304808 NPI number — LONGS DRUG STORES CALIFORNIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGS DRUG STORES CALIFORNIA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LONGS DRUG STORE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558304808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 N CIVIC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94596-3815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3960 PALMER PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80909-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-591-0395
Provider Business Practice Location Address Fax Number:
719-380-0833
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALLIDAY
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGED CARE ADMINISTRATOR
Authorized Official Telephone Number:
925-210-6659

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY 2463 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03024635 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0612095 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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