Provider Demographics
NPI:1780714089
Name:FRESNO PHARMACY, INC
Entity type:Organization
Organization Name:FRESNO PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINH
Authorized Official - Middle Name:QUI
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-255-8085
Mailing Address - Street 1:4917 E. KINGS CANYON RD.
Mailing Address - Street 2:# 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727
Mailing Address - Country:US
Mailing Address - Phone:559-255-8085
Mailing Address - Fax:559-255-2342
Practice Address - Street 1:4917 E. KINGS CANYON RD.
Practice Address - Street 2:# 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727
Practice Address - Country:US
Practice Address - Phone:559-255-8085
Practice Address - Fax:559-255-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY444873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6475210001Medicare NSC