Provider Demographics
NPI:1154055341
Name:MAIN STREET PHARMACY INCORPORATED
Entity type:Organization
Organization Name:MAIN STREET PHARMACY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA GRACE
Authorized Official - Middle Name:GINES
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:951-279-3125
Mailing Address - Street 1:823 S MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:823 S MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3409
Practice Address - Country:US
Practice Address - Phone:951-279-3125
Practice Address - Fax:951-279-3127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy