Provider Demographics
NPI:1578574158
Name:FISHERS DRUG STORE
Entity Type:Organization
Organization Name:FISHERS DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:626-286-3133
Mailing Address - Street 1:9601 LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-2109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9601 LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-2109
Practice Address - Country:US
Practice Address - Phone:626-286-3133
Practice Address - Fax:626-287-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43708333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0548745OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA437080Medicaid