# WATERFRONT PHARMACY LTC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114696382
- **Authorized official:** MR. CHANDRA KADIYALA (CEO)
- **Authorized official phone:** (509) 392-1958

## Contact information

- **Practice address:** 123 S COMMERCE ST STE A, STOCKTON, CA 95202-2837
- **Practice address phone:** (209) 298-1715
- **Practice address fax:** (559) 369-2408
- **Mailing address:** 123 S COMMERCE ST STE A, STOCKTON, CA 95202-2837
- **Mailing address phone:** (209) 929-1093
- **Mailing address fax:** (209) 929-1096

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336L0003X | Long Term Care Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 09/09/2021
- **Last updated:** 04/18/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | PHY58030 | PHARMACY LICENSE | CA |