Provider Demographics
NPI:1346383056
Name:MEDICAL ARTS PHARMACY LLC
Entity Type:Organization
Organization Name:MEDICAL ARTS PHARMACY LLC
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECCTOR
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 1:13847 E 14TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2632
Mailing Address - Country:US
Mailing Address - Phone:510-357-1881
Mailing Address - Fax:510-357-1895
Practice Address - Street 1:13847 E 14TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2632
Practice Address - Country:US
Practice Address - Phone:510-357-1881
Practice Address - Fax:510-357-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1346383056Medicaid
CA59184OtherPHARMACY LICENSE