Provider Demographics
NPI:1790082089
Name:CROWN VALLEY PHARMACY
Entity Type:Organization
Organization Name:CROWN VALLEY PHARMACY
Other - Org Name:CROWN VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, STORE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOWDHURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-269-9500
Mailing Address - Street 1:3720 SIERRA HWY
Mailing Address - Street 2:UNIT G
Mailing Address - City:ACTON
Mailing Address - State:CA
Mailing Address - Zip Code:93510-1272
Mailing Address - Country:US
Mailing Address - Phone:661-269-9500
Mailing Address - Fax:661-269-9501
Practice Address - Street 1:3720 SIERRA HWY
Practice Address - Street 2:UNIT G
Practice Address - City:ACTON
Practice Address - State:CA
Practice Address - Zip Code:93510-1272
Practice Address - Country:US
Practice Address - Phone:661-269-9500
Practice Address - Fax:661-269-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY515523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128956OtherPK