Healthcare Provider Details

I. General information

NPI: 1780795377
Provider Name (Legal Business Name): WEST SIDE DRUG CO A CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 O ST
FIREBAUGH CA
93622-2224
US

IV. Provider business mailing address

1101 O ST
FIREBAUGH CA
93622-2224
US

V. Phone/Fax

Practice location:
  • Phone: 559-659-2159
  • Fax: 559-659-2985
Mailing address:
  • Phone: 559-659-2159
  • Fax: 559-659-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY10636
License Number StateCA

VIII. Authorized Official

Name: JEFF LOUIE
Title or Position: TRES
Credential:
Phone: 559-659-2159