Provider Demographics
NPI:1376675751
Name:THE APOTHECARY EASTMONT TOWN CENTER
Entity Type:Organization
Organization Name:THE APOTHECARY EASTMONT TOWN CENTER
Other - Org Name:THE APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PONDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:510-638-7323
Mailing Address - Street 1:7200 BANCROFT AVE
Mailing Address - Street 2:SUITE #268
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2468
Mailing Address - Country:US
Mailing Address - Phone:510-638-7323
Mailing Address - Fax:510-430-2860
Practice Address - Street 1:7200 BANCROFT AVE
Practice Address - Street 2:SUITE #268
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2468
Practice Address - Country:US
Practice Address - Phone:510-638-7323
Practice Address - Fax:510-430-2860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY466253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY46625OtherPHARMACY STATE LICENSE
CAPHA466250Medicaid
CA5613193OtherNCPDP
CA5613193OtherNCPDP
CAPHA466250Medicaid