=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912097957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGS DRUG STORES CALIFORNIA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12276 HESPERIA RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-5838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-962-8007
-----------------------------------------------------
Fax | 760-962-8011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 N CIVIC DR
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94596-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE ADMINISTRATOR
-----------------------------------------------------
Name | AMY HALLIDAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 925-210-6659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY47581
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------