Provider Demographics
NPI:1033109319
Name:SILVER SPRAY PHARMACY
Entity Type:Organization
Organization Name:SILVER SPRAY PHARMACY
Other - Org Name:SILVER SPRAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-327-4248
Mailing Address - Street 1:2191 NILES ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93305-5168
Mailing Address - Country:US
Mailing Address - Phone:661-327-4248
Mailing Address - Fax:661-327-1025
Practice Address - Street 1:2191 NILES ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-5168
Practice Address - Country:US
Practice Address - Phone:661-327-4248
Practice Address - Fax:661-327-1025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY434913336C0003X, 3336C0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103-310-9319Medicaid
1996907OtherPK
0817670001Medicare NSC