Provider Demographics
NPI:1487912333
Name:RELIANCE IMPERIAL PHARMACY LLC
Entity type:Organization
Organization Name:RELIANCE IMPERIAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAHMAJI
Authorized Official - Middle Name:
Authorized Official - Last Name:VALIVETI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-768-6000
Mailing Address - Street 1:801 E BIRCH ST
Mailing Address - Street 2:STE # 4
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-5925
Mailing Address - Country:US
Mailing Address - Phone:760-768-6000
Mailing Address - Fax:760-768-6006
Practice Address - Street 1:801 E BIRCH ST
Practice Address - Street 2:STE # 4
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-5925
Practice Address - Country:US
Practice Address - Phone:760-768-6000
Practice Address - Fax:760-768-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-29
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY50953333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY50953OtherCALIFORNIA STATE BOARD OF PHARMACY PERMIT