MEDICARE: LONGS DRUG STORES CALIFORNIA INC

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	PHY 2463	CO
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0612095	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1558304808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUG STORES CALIFORNIA INC

Provider Business Mailing Address
First Line	:	141 N CIVIC DR
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94596-3815
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3960 PALMER PARK BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-3404
Country	:	US
Telephone Number	:	719-591-0395
Fax Number	:	719-380-0833

Authorized Official
Title or Position	:	MANAGED CARE ADMINISTRATOR
Name	:	AMY HALLIDAY
Credential	:
Telephone Number	:	925-210-6659

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	09/11/2025

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