Provider Demographics
NPI:1932769684
Name:EXCEL SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:EXCEL SPECIALTY PHARMACY LLC
Other - Org Name:EXCEL SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEOLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:EDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-375-1241
Mailing Address - Street 1:3338 DUNCAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-5007
Mailing Address - Country:US
Mailing Address - Phone:559-375-1241
Mailing Address - Fax:
Practice Address - Street 1:604 N MAGNOLIA AVE STE 105
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-9205
Practice Address - Country:US
Practice Address - Phone:302-229-5481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-15
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932769684Medicaid