Healthcare Provider Details

I. General information

NPI: 1972594448
Provider Name (Legal Business Name): FRUITVALE MEDICAL CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 INTERNATIONAL BLVD
OAKLAND CA
94601-2204
US

IV. Provider business mailing address

3024 INTERNATIONAL BLVD
OAKLAND CA
94601-2204
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-1005
  • Fax: 510-535-9374
Mailing address:
  • Phone: 510-535-1005
  • Fax: 510-535-9374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY35207
License Number StateCA

VIII. Authorized Official

Name: MR. KUO LIANG YANG
Title or Position: PHARMACIST OWNER
Credential:
Phone: 510-535-1005