Provider Demographics
NPI:1679638001
Name:ABALA PHARMACY
Entity Type:Organization
Organization Name:ABALA PHARMACY
Other - Org Name:ABALA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-832-7080
Mailing Address - Street 1:PO BOX 1943
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95378-1943
Mailing Address - Country:US
Mailing Address - Phone:209-832-7080
Mailing Address - Fax:209-832-3889
Practice Address - Street 1:550 W EATON AVE STE B
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3462
Practice Address - Country:US
Practice Address - Phone:209-832-7080
Practice Address - Fax:209-832-3889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY463433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA463430Medicaid
CAPHA46343Medicaid
2112189OtherPK