Provider Demographics
NPI:1912323155
Name:MERCURY PHARMACY CORPORATION
Entity Type:Organization
Organization Name:MERCURY PHARMACY CORPORATION
Other - Org Name:CENTRAL PHARMACY #002
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:DUENAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-200-4411
Mailing Address - Street 1:3495 SONOMA BLVD STE K
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2984
Mailing Address - Country:US
Mailing Address - Phone:707-200-4411
Mailing Address - Fax:707-652-5906
Practice Address - Street 1:3495 SONOMA BLVD STE K
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2984
Practice Address - Country:US
Practice Address - Phone:707-200-4411
Practice Address - Fax:707-652-5906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA517903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912323155Medicaid