Provider Demographics
NPI:1124033519
Name:BROOKVALE MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:BROOKVALE MEDICAL CENTER PHARMACY
Other - Org Name:PARK PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-235-4441
Mailing Address - Street 1:2101 VALE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806
Mailing Address - Country:US
Mailing Address - Phone:510-235-4443
Mailing Address - Fax:510-235-5527
Practice Address - Street 1:2101 VALE RD
Practice Address - Street 2:STE 100
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-235-4443
Practice Address - Fax:510-235-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY22575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA225750Medicaid