Provider Demographics
NPI:1689656704
Name:SHIVSA
Entity Type:Organization
Organization Name:SHIVSA
Other - Org Name:BOIES MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRATAP
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-298-1715
Mailing Address - Street 1:828 DELBON AVE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382
Mailing Address - Country:US
Mailing Address - Phone:209-634-8511
Mailing Address - Fax:209-634-3839
Practice Address - Street 1:828 DELBON AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382
Practice Address - Country:US
Practice Address - Phone:209-634-8511
Practice Address - Fax:209-634-3839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X, 3336S0011X, 335E00000X
CAPHY555683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168554OtherPK
CA1689656704Medicaid
CAPHA208790Medicaid