Healthcare Provider Details

I. General information

NPI: 1487691903
Provider Name (Legal Business Name): LUCKY STORES II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EL PASEO DE SARATOGA
SAN JOSE CA
95130-1616
US

IV. Provider business mailing address

200 EL PASEO DE SARATOGA
SAN JOSE CA
95130-1616
US

V. Phone/Fax

Practice location:
  • Phone: 408-370-1205
  • Fax: 408-370-1397
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY42024
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