Provider Demographics
NPI:1164511713
Name:BIG A DRUG STORE INC
Entity Type:Organization
Organization Name:BIG A DRUG STORE INC
Other - Org Name:DRUG BARN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:562-633-9578
Mailing Address - Street 1:4925 JUNIPERO SERRA BLVD
Mailing Address - Street 2:
Mailing Address - City:COLMA
Mailing Address - State:CA
Mailing Address - Zip Code:94014-3216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4925 JUNIPERO SERRA BLVD
Practice Address - Street 2:
Practice Address - City:COLMA
Practice Address - State:CA
Practice Address - Zip Code:94014-3216
Practice Address - Country:US
Practice Address - Phone:650-997-3985
Practice Address - Fax:650-994-8739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43396333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA433960Medicaid
0547743OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA433960Medicaid