1528001310 NPI number — LONGS DRUG STORES CALIFORNIA INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528001310 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:
Provider Other Organization Name Type Code:
6
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:
1528001310
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:
735 NW GILMAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-8941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-313-0333
Provider Business Practice Location Address Fax Number:
425-313-9023
Provider Enumeration Date:
06/13/2006

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:  CF56116 , registered in the state of WA ; 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: 6020978 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4926210 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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