Provider Demographics
NPI:1831136357
Name:LUCKY STORES II LLC
Entity Type:Organization
Organization Name:LUCKY STORES II LLC
Other - Org Name:SAVON DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NEW STORE ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-916-4463
Mailing Address - Street 1:4708 MANZANITA AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4708 MANZANITA AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0823
Practice Address - Country:US
Practice Address - Phone:916-979-9100
Practice Address - Fax:916-979-9861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43410333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0577392OtherOTHER ID NUMBER-COMMERCIAL NUMBER