Provider Demographics
NPI:1386673556
Name:OMEGAMARG PHARMACY INC
Entity Type:Organization
Organization Name:OMEGAMARG PHARMACY INC
Other - Org Name:JACKS DRUG STORE AND MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KATPELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-454-1451
Mailing Address - Street 1:121 TUNSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2616
Mailing Address - Country:US
Mailing Address - Phone:415-454-1451
Mailing Address - Fax:415-454-2865
Practice Address - Street 1:121 TUNSTEAD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2616
Practice Address - Country:US
Practice Address - Phone:415-454-1451
Practice Address - Fax:415-454-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
CAPHY490293336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA375550Medicaid
1996097OtherPK
CAPHA375550Medicaid