Provider Demographics
NPI:1700924180
Name:VALLE VERDE PHARMACY, INC
Entity Type:Organization
Organization Name:VALLE VERDE PHARMACY, INC
Other - Org Name:VALLE VERDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:DEMBSKI
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:831-426-0200
Mailing Address - Street 1:240 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3137
Mailing Address - Country:US
Mailing Address - Phone:831-728-2239
Mailing Address - Fax:831-728-9386
Practice Address - Street 1:240 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3137
Practice Address - Country:US
Practice Address - Phone:831-728-2239
Practice Address - Fax:831-728-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY217283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA217280Medicaid
CAPHY21728OtherSTATE PHARMACY LIC
CA05-67644OtherNABP
CAPHA217280Medicaid