Provider Demographics
NPI:1407301468
Name:PRIMECARE PHARMACY LLC
Entity Type:Organization
Organization Name:PRIMECARE PHARMACY LLC
Other - Org Name:PRIMECARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:630-242-8969
Mailing Address - Street 1:32144 AGOURA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361
Mailing Address - Country:US
Mailing Address - Phone:818-964-1000
Mailing Address - Fax:818-964-1200
Practice Address - Street 1:32144 AGOURA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:818-964-1000
Practice Address - Fax:818-964-1200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMC LYONS HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-19
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3336C0003X
CAPHY556843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407301468Medicaid