Provider Demographics
NPI:1417047739
Name:ADVANCE PHARMACY INC.
Entity Type:Organization
Organization Name:ADVANCE PHARMACY INC.
Other - Org Name:88 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:626-576-7633
Mailing Address - Street 1:88 S PALM AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3101
Mailing Address - Country:US
Mailing Address - Phone:626-576-7633
Mailing Address - Fax:626-576-2243
Practice Address - Street 1:88 S PALM AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3101
Practice Address - Country:US
Practice Address - Phone:626-576-7633
Practice Address - Fax:626-576-2243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY469763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0548656OtherNCPDP PROVIDER NUMBER
CAPHA469760Medicaid
5534550001Medicare ID - Type Unspecified