Provider Demographics
NPI:1053397950
Name:PALACE PHARMACY
Entity type:Organization
Organization Name:PALACE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LC
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:415-467-5232
Mailing Address - Street 1:2800 GENEVA AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-1523
Mailing Address - Country:US
Mailing Address - Phone:415-467-5232
Mailing Address - Fax:415-467-5234
Practice Address - Street 1:2800 GENEVA AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-1523
Practice Address - Country:US
Practice Address - Phone:415-467-5232
Practice Address - Fax:415-467-5234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA222270Medicaid
CA0531219OtherNCPDP/NABP