Provider Demographics
NPI:1619203841
Name:FRUITVALE AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:FRUITVALE AVENUE PHARMACY INC
Other - Org Name:FRUITVALE AVENUE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALPESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:510-406-3089
Mailing Address - Street 1:7400 MACARTHUR BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2939
Mailing Address - Country:US
Mailing Address - Phone:510-261-1412
Mailing Address - Fax:510-261-1414
Practice Address - Street 1:2693 FRUITVALE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2034
Practice Address - Country:US
Practice Address - Phone:510-261-1412
Practice Address - Fax:510-261-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500643336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122526OtherPK