1932105897 NPI number — MIDTOWN PHARMACY PC

Table of content: (NPI 1932105897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932105897 NPI number — MIDTOWN PHARMACY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDTOWN PHARMACY PC
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:
MIDTOWN PHARMACY PROFESSIONAL CORPORATION
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:
1932105897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2173 HARBOR BAY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94502-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-864-4199
Provider Business Mailing Address Fax Number:
510-864-4196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2173 HARBOR BAY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94502-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-864-4199
Provider Business Practice Location Address Fax Number:
510-864-4196
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLEMAN
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
STEPHEN
Authorized Official Title or Position:
PHARMACIST/C.E.O.
Authorized Official Telephone Number:
510-864-4199

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PHY53944 , 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: PHA53944 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992840 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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