Provider Demographics
NPI:1356451017
Name:RALEYS INC
Entity Type:Organization
Organization Name:RALEYS INC
Other - Org Name:RALEYS 213
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY AND GM
Authorized Official - Prefix:
Authorized Official - First Name:FLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDERGRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-373-6146
Mailing Address - Street 1:692A FREEMAN LANE
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:692A FREEMAN LANE
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949
Practice Address - Country:US
Practice Address - Phone:530-272-2496
Practice Address - Fax:530-274-0632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY34547333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA345470Medicaid
0592344OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0592344OtherOTHER ID NUMBER-COMMERCIAL NUMBER