Provider Demographics
NPI:1003821638
Name:CERES DRUG STORE, INC.
Entity Type:Organization
Organization Name:CERES DRUG STORE, INC.
Other - Org Name:CERES DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMERNES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:209-537-0718
Mailing Address - Street 1:2929 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-3222
Mailing Address - Country:US
Mailing Address - Phone:209-537-0718
Mailing Address - Fax:209-537-4252
Practice Address - Street 1:2929 4TH ST
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-3222
Practice Address - Country:US
Practice Address - Phone:209-537-0718
Practice Address - Fax:209-537-4252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CAPHY307733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA307730Medicaid
CAPHY30773Medicaid
CAPHY57145Medicaid
2034704OtherPK