Provider Demographics
NPI:1245241827
Name:ALCOSTA PHARMACY ASSOCIATES INC
Entity Type:Organization
Organization Name:ALCOSTA PHARMACY ASSOCIATES INC
Other - Org Name:CUSTOM CARE COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASUER
Authorized Official - Prefix:
Authorized Official - First Name:MARY KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-830-0581
Mailing Address - Street 1:124 MARKET PL
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4740
Mailing Address - Country:US
Mailing Address - Phone:925-830-4631
Mailing Address - Fax:925-830-0125
Practice Address - Street 1:124 MARKET PL
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4740
Practice Address - Country:US
Practice Address - Phone:925-830-4631
Practice Address - Fax:925-830-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CAPHY414513336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA414510Medicaid
2036044OtherPK
CAPHA414510Medicaid