Provider Demographics
NPI:1871608802
Name:STAR PHARMACY LLC
Entity type:Organization
Organization Name:STAR PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANDYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-366-3653
Mailing Address - Street 1:6448 HALLEE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252
Mailing Address - Country:US
Mailing Address - Phone:760-366-3653
Mailing Address - Fax:760-366-3674
Practice Address - Street 1:6448 HALLEE RD STE 2
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-1908
Practice Address - Country:US
Practice Address - Phone:760-366-3653
Practice Address - Fax:760-366-3674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY343473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA343470Medicaid
1998973OtherPK
0590667OtherOTHER ID NUMBER-COMMERCIAL NUMBER