Provider Demographics
NPI:1730202425
Name:RITEAID 5614
Entity type:Organization
Organization Name:RITEAID 5614
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:SOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:619-421-4872
Mailing Address - Street 1:740 OTAY LAKES RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92104-6915
Mailing Address - Country:US
Mailing Address - Phone:619-421-4872
Mailing Address - Fax:619-421-2452
Practice Address - Street 1:740 OTAY LAKES RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6915
Practice Address - Country:US
Practice Address - Phone:619-421-4872
Practice Address - Fax:619-421-2452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA422303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy