Provider Demographics
NPI:1215073259
Name:HALLERS PHARMACY AND MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:HALLERS PHARMACY AND MEDICAL SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASRAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-797-2772
Mailing Address - Street 1:37323 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3702
Mailing Address - Country:US
Mailing Address - Phone:510-797-2772
Mailing Address - Fax:510-797-4986
Practice Address - Street 1:37323 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3702
Practice Address - Country:US
Practice Address - Phone:510-797-2772
Practice Address - Fax:510-797-4986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CA456743336S0011X
CAPHY456743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45674OtherSTATE BOARD OF PHARMACY PERMIT
CAPHA456740Medicaid