Healthcare Provider Details

I. General information

NPI: 1619203841
Provider Name (Legal Business Name): FRUITVALE AVENUE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2693 FRUITVALE AVE
OAKLAND CA
94601-2034
US

IV. Provider business mailing address

7400 MACARTHUR BLVD STE B
OAKLAND CA
94605-2939
US

V. Phone/Fax

Practice location:
  • Phone: 510-261-1412
  • Fax: 510-261-1414
Mailing address:
  • Phone: 510-261-1412
  • Fax: 510-261-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50064
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KALPESH PATEL
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 510-406-3089