Provider Demographics
NPI:1104807460
Name:REPUBLIC PHARMACY CO., INC.
Entity type:Organization
Organization Name:REPUBLIC PHARMACY CO., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:415-982-8641
Mailing Address - Street 1:704 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-2114
Mailing Address - Country:US
Mailing Address - Phone:415-982-8641
Mailing Address - Fax:
Practice Address - Street 1:704 GRANT AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-2114
Practice Address - Country:US
Practice Address - Phone:415-982-8641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY694333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPH00A6940Medicaid