Provider Demographics
NPI:1881232213
Name:VISALIA PHARMACY INC
Entity Type:Organization
Organization Name:VISALIA PHARMACY INC
Other - Org Name:VISALIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:559-667-9292
Mailing Address - Street 1:444 NW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-3624
Mailing Address - Country:US
Mailing Address - Phone:559-931-1122
Mailing Address - Fax:
Practice Address - Street 1:444 NW 3RD AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-3624
Practice Address - Country:US
Practice Address - Phone:559-667-9292
Practice Address - Fax:559-667-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2056FQ6SMedicaid