1093751950 NPI number — FORTUNE PHARMACY INC

Table of content: (NPI 1093751950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093751950 NPI number — FORTUNE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORTUNE PHARMACY 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:
ALHAMBRA PROFESSIONAL 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:
1093751950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 S GARFIELD AVE
Provider Second Line Business Mailing Address:
#104
Provider Business Mailing Address City Name:
ALHAMBRA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91801-3892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-458-8909
Provider Business Mailing Address Fax Number:
626-458-8950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 S GARFIELD AVE
Provider Second Line Business Practice Location Address:
#104
Provider Business Practice Location Address City Name:
ALHAMBRA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91801-3892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-458-8909
Provider Business Practice Location Address Fax Number:
626-458-8950
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUO
Authorized Official First Name:
KAM-YING
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
626-458-8909

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY46885 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X , with the licence number: PHY46885 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PHA468850 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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