Provider Demographics
NPI:1033303177
Name:TWELVE BRIDGES PHARMACY, INC.
Entity type:Organization
Organization Name:TWELVE BRIDGES PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HUYQUANG
Authorized Official - Middle Name:CHI
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-415-0722
Mailing Address - Street 1:835 TWELVE BRIDGES DRIVE
Mailing Address - Street 2:SUITE 82
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-8817
Mailing Address - Country:US
Mailing Address - Phone:916-409-9500
Mailing Address - Fax:916-409-9400
Practice Address - Street 1:835 TWELVE BRIDGES DRIVE
Practice Address - Street 2:SUITE 82
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-8817
Practice Address - Country:US
Practice Address - Phone:916-409-9500
Practice Address - Fax:916-409-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY48802333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6024860001Medicare NSC