Healthcare Provider Details

I. General information

NPI: 1861439291
Provider Name (Legal Business Name): LUCKY STORES II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 MOWRY AVE
FREMONT CA
94538-1045
US

IV. Provider business mailing address

5000 MOWRY AVE
FREMONT CA
94538-1045
US

V. Phone/Fax

Practice location:
  • Phone: 510-744-9330
  • Fax: 510-744-9518
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY43769
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LORENZO TORRES
Title or Position: NEW STORE ENROLLMENTS
Credential:
Phone: 847-916-4463