Provider Demographics
NPI:1528001310
Name:LONGS DRUG STORES CALIFORNIA INC
Entity Type:Organization
Organization Name:LONGS DRUG STORES CALIFORNIA INC
Other - Org Name:LONGS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-210-6659
Mailing Address - Street 1:141 N CIVIC DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:735 NW GILMAN BLVD
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8941
Practice Address - Country:US
Practice Address - Phone:425-313-0333
Practice Address - Fax:425-313-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF56116333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6020978Medicaid
4926210OtherOTHER ID NUMBER-COMMERCIAL NUMBER