Provider Demographics
NPI:1629184007
Name:MERCY PHARMACY GROUP, INC
Entity Type:Organization
Organization Name:MERCY PHARMACY GROUP, INC
Other - Org Name:CARSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-328-0982
Mailing Address - Street 1:21720 S VERMONT AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2127
Mailing Address - Country:US
Mailing Address - Phone:310-328-0982
Mailing Address - Fax:310-328-8080
Practice Address - Street 1:21720 S VERMONT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2127
Practice Address - Country:US
Practice Address - Phone:310-328-0982
Practice Address - Fax:310-328-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA223530Medicaid