Provider Demographics
NPI:1467137802
Name:WALNUT CREEK RX LLC
Entity Type:Organization
Organization Name:WALNUT CREEK RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRATAP
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-298-1715
Mailing Address - Street 1:112 LA CASA VIA STE 100
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3016
Mailing Address - Country:US
Mailing Address - Phone:925-939-6312
Mailing Address - Fax:925-939-5639
Practice Address - Street 1:112 LA CASA VIA STE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3016
Practice Address - Country:US
Practice Address - Phone:925-939-6312
Practice Address - Fax:925-939-5639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962061648Medicaid