Provider Demographics
NPI:1821033143
Name:TRI-VALLEY PHARMACY CORPORATION
Entity Type:Organization
Organization Name:TRI-VALLEY PHARMACY CORPORATION
Other - Org Name:STONERIDGE PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:925-463-2248
Mailing Address - Street 1:5720 STONERIDGE MALL RD
Mailing Address - Street 2:#150
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-2828
Mailing Address - Country:US
Mailing Address - Phone:925-463-2248
Mailing Address - Fax:925-463-5615
Practice Address - Street 1:5720 STONERIDGE MALL RD
Practice Address - Street 2:#150
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-2828
Practice Address - Country:US
Practice Address - Phone:925-463-2248
Practice Address - Fax:925-463-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY474323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2003041OtherPK
CAPHA222970Medicaid