Provider Demographics
NPI:1457341299
Name:MISSION PHARMACY
Entity Type:Organization
Organization Name:MISSION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:MR
Authorized Official - First Name:KAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:510-813-8687
Mailing Address - Street 1:22138 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-2645
Mailing Address - Country:US
Mailing Address - Phone:510-581-8540
Mailing Address - Fax:510-581-5873
Practice Address - Street 1:22138 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-2645
Practice Address - Country:US
Practice Address - Phone:510-581-8540
Practice Address - Fax:510-581-5873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY471643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA471640Medicaid