Provider Demographics
NPI:1164713517
Name:EUREKA PHARMACY LLC
Entity Type:Organization
Organization Name:EUREKA PHARMACY LLC
Other - Org Name:CLONEYS LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRATAP
Authorized Official - Middle Name:KRISHNA
Authorized Official - Last Name:ANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-298-1715
Mailing Address - Street 1:525 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1032
Mailing Address - Country:US
Mailing Address - Phone:707-443-8452
Mailing Address - Fax:707-443-3059
Practice Address - Street 1:525 5TH ST STE B
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1032
Practice Address - Country:US
Practice Address - Phone:707-443-8452
Practice Address - Fax:707-443-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 3336S0011X
CA54375333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164713517Medicaid
2129858OtherPK
CAGH519AOtherMEDICARE PTAN
CA4691000003Medicare NSC
CAPHY 54375OtherBOARD OF PHARMACY PERMIT