1679638001 NPI number — ABALA PHARMACY

Table of content: (NPI 1679638001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679638001 NPI number — ABALA PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABALA PHARMACY
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:
ABALA PHARMACY
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:
1679638001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1943
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95378-1943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-832-7080
Provider Business Mailing Address Fax Number:
209-832-3889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 W EATON AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95376-3462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-832-7080
Provider Business Practice Location Address Fax Number:
209-832-3889
Provider Enumeration Date:
12/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ABALA
Authorized Official First Name:
SHIRLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST OWNER
Authorized Official Telephone Number:
209-832-7080

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY46343 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PHA463430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PHA46343 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2112189 . This is a "PK" identifier . This identifiers is of the category "OTHER".