Provider Demographics
NPI:1912912544
Name:RANCHO PHARMACY
Entity Type:Organization
Organization Name:RANCHO PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEINOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-823-7658
Mailing Address - Street 1:1367 E YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1367 E YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5003
Practice Address - Country:US
Practice Address - Phone:209-823-7658
Practice Address - Fax:209-823-8552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY471573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0550687OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA471570Medicaid
0550687OtherOTHER ID NUMBER
0550687OtherOTHER ID NUMBER-COMMERCIAL NUMBER