MEDICARE: LUCKY STORES II LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PHY43379	CA
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0576225	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1477590149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCKY STORES II LLC

Provider Business Mailing Address
First Line	:	3705 EL CAMINO REAL
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95051-2614
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3705 EL CAMINO REAL
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95051-2614
Country	:	US
Telephone Number	:	408-249-6700
Fax Number	:	408-249-7599

Authorized Official
Title or Position	:	NEW STORE ENROLLMENTS
Name	:	LORENZO TORRES
Credential	:
Telephone Number	:	847-916-4463

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	09/11/2025

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