Provider Demographics
NPI:1861475519
Name:GERALD C DAVALOS
Entity Type:Organization
Organization Name:GERALD C DAVALOS
Other - Org Name:ACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DAVALOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:415-731-3535
Mailing Address - Street 1:2505 NORIEGA STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-4126
Mailing Address - Country:US
Mailing Address - Phone:415-731-3535
Mailing Address - Fax:415-731-8650
Practice Address - Street 1:2505 NORIEGA STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-4126
Practice Address - Country:US
Practice Address - Phone:415-731-3535
Practice Address - Fax:415-731-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY22384333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA223840Medicaid
0514530001Medicare ID - Type Unspecified