=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649657172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALAMEDA PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2015
-----------------------------------------------------
Last Update Date | 03/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1555 DOOLITTLE DR STE 160
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-362-7255
-----------------------------------------------------
Fax | 510-362-7256
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1555 DOOLITTLE DR STE 160
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-362-7255
-----------------------------------------------------
Fax | 510-362-7256
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | ARDIE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-362-7254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 52058
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------