Provider Demographics
NPI:1932105897
Name:MIDTOWN PHARMACY PC
Entity Type:Organization
Organization Name:MIDTOWN PHARMACY PC
Other - Org Name:MIDTOWN PHARMACY PROFESSIONAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:510-864-4199
Mailing Address - Street 1:2173 HARBOR BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-3019
Mailing Address - Country:US
Mailing Address - Phone:510-864-4199
Mailing Address - Fax:510-864-4196
Practice Address - Street 1:2173 HARBOR BAY PKWY
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-3019
Practice Address - Country:US
Practice Address - Phone:510-864-4199
Practice Address - Fax:510-864-4196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CAPHY539443336L0003X
CAPHY433003336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA53944Medicaid
1992840OtherPK
1992840OtherPK
CAPHA433000Medicaid