Provider Demographics
NPI:1063566446
Name:SMART PHARMACY, LLC
Entity type:Organization
Organization Name:SMART PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMCIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PRATAP
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-298-1715
Mailing Address - Street 1:1801 E MARCH LN
Mailing Address - Street 2:BLDG B STE 280
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-474-2888
Mailing Address - Fax:209-474-3328
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:BLDG B STE 280
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-474-2888
Practice Address - Fax:209-474-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336L0003X, 333600000X
CAPHY497853336C0003X, 3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1063566446Medicaid
2113537OtherPK
2113537OtherPK