Healthcare Provider Details

I. General information

NPI: 1780685263
Provider Name (Legal Business Name): LUCKY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/10/2021
Certification Date: 04/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W LAS TUNAS DR STE 100
SAN GABRIEL CA
91776-1236
US

IV. Provider business mailing address

416 W LAS TUNAS DR STE 100
SAN GABRIEL CA
91776-1236
US

V. Phone/Fax

Practice location:
  • Phone: 626-282-2277
  • Fax: 626-458-8329
Mailing address:
  • Phone: 626-282-2277
  • Fax: 626-458-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY48786
License Number StateCA

VIII. Authorized Official

Name: SHIUFONG YAN
Title or Position: PRESIDENT
Credential:
Phone: 626-282-2277