Healthcare Provider Details

I. General information

NPI: 1700895034
Provider Name (Legal Business Name): 2500 MILVIA PRESCRIPTION PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MILVIA ST STE 130
BERKELEY CA
94704-2636
US

IV. Provider business mailing address

2500 MILVIA ST STE 130
BERKELEY CA
94704-2636
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-0773
  • Fax: 510-548-6980
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY22894
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRIAN QUON
Title or Position: MANAGER
Credential: CPHT
Phone: 510-548-0773