Provider Demographics
NPI:1386633642
Name:STAR DRUG CENTER
Entity Type:Organization
Organization Name:STAR DRUG CENTER
Other - Org Name:STAR DRUG CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:909-795-2457
Mailing Address - Street 1:1151 CALIMESA BLVD
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-1549
Mailing Address - Country:US
Mailing Address - Phone:909-795-2457
Mailing Address - Fax:
Practice Address - Street 1:1151 CALIMESA BLVD
Practice Address - Street 2:
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1549
Practice Address - Country:US
Practice Address - Phone:909-795-2457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIMESA PLAZA DRUG, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-19
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY37324333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA373240Medicaid