Provider Demographics
NPI:1811081219
Name:GEMMEL PHARMACY OF ALTA LOMA
Entity type:Organization
Organization Name:GEMMEL PHARMACY OF ALTA LOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NEEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:909-987-1701
Mailing Address - Street 1:8750 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8750 BASELINE RD
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-5503
Practice Address - Country:US
Practice Address - Phone:909-987-1707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEMMEL PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY48868333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811081219Medicaid
0524341OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0524341OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CA1811081219Medicaid