Provider Demographics
NPI:1225187693
Name:LC MISSION LLC
Entity Type:Organization
Organization Name:LC MISSION LLC
Other - Org Name:COMMUNITY PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VERA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAMOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-422-8477
Mailing Address - Street 1:2462 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-2415
Mailing Address - Country:US
Mailing Address - Phone:415-648-0815
Mailing Address - Fax:415-285-1237
Practice Address - Street 1:2462 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2415
Practice Address - Country:US
Practice Address - Phone:415-648-0815
Practice Address - Fax:415-285-1237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY557223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170290OtherPK
CA1225187693Medicaid