Provider Demographics
NPI:1528157179
Name:LEITERS CAMBRIAN PARK DRUGS INC
Entity type:Organization
Organization Name:LEITERS CAMBRIAN PARK DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-292-6772
Mailing Address - Street 1:1700 PARK AVE
Mailing Address - Street 2:STE 30
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2033
Mailing Address - Country:US
Mailing Address - Phone:408-292-6772
Mailing Address - Fax:408-288-8252
Practice Address - Street 1:1700 PARK AVE
Practice Address - Street 2:STE 30
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2033
Practice Address - Country:US
Practice Address - Phone:408-292-6772
Practice Address - Fax:408-288-8252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336M0002X, 333600000X
CAPHY459403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY45940Medicaid
0546107OtherNCPDP PROVIDER IDENTIFICATION NUMBER