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	3336L0003X	Long Term Care Pharmacy	PHY43550	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0579194	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1740227263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCKY STORES II LLC

Provider Business Mailing Address
First Line	:	6843 MISSION ST
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94014-2006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6843 MISSION ST
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94014-2006
Country	:	US
Telephone Number	:	650-992-9490
Fax Number	:	650-992-9504

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	:	08/22/2020

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Directions to “LUCKY STORES II LLC ” Practice Location

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