Provider Demographics
NPI:1972594448
Name:FRUITVALE MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:FRUITVALE MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KUO LIANG
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-535-1005
Mailing Address - Street 1:3024 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2204
Mailing Address - Country:US
Mailing Address - Phone:510-535-1005
Mailing Address - Fax:510-535-9374
Practice Address - Street 1:3024 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2204
Practice Address - Country:US
Practice Address - Phone:510-535-1005
Practice Address - Fax:510-535-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY35207333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0594538OtherALAMEDA ALLIANCE