Provider Demographics
NPI:1649657172
Name:ALAMEDA PHARMACY LLC
Entity type:Organization
Organization Name:ALAMEDA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ARDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-362-7254
Mailing Address - Street 1:1555 DOOLITTLE DR STE 160
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2272
Mailing Address - Country:US
Mailing Address - Phone:510-362-7255
Mailing Address - Fax:510-362-7256
Practice Address - Street 1:1555 DOOLITTLE DR STE 160
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-2272
Practice Address - Country:US
Practice Address - Phone:510-362-7255
Practice Address - Fax:510-362-7256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA520583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151752OtherPK