Provider Demographics
NPI:1114696382
Name:WATERFRONT PHARMACY LTC LLC
Entity Type:Organization
Organization Name:WATERFRONT PHARMACY LTC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KADIYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-392-1958
Mailing Address - Street 1:123 S COMMERCE ST STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2837
Mailing Address - Country:US
Mailing Address - Phone:209-929-1093
Mailing Address - Fax:209-929-1096
Practice Address - Street 1:123 S COMMERCE ST STE A
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2837
Practice Address - Country:US
Practice Address - Phone:209-298-1715
Practice Address - Fax:559-369-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY58030OtherPHARMACY LICENSE