Organization
WATERFRONT PHARMACY LTC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHANDRA KADIYALA (CEO)
(509) 392-1958
Entity
Organization
Contact information
Practice address
123 S COMMERCE ST STE A, STOCKTON, CA 95202-2837
(209) 298-1715
(559) 369-2408
Mailing address
123 S COMMERCE ST STE A, STOCKTON, CA 95202-2837
(209) 929-1093
(209) 929-1096
Taxonomy
Speciality
Code
Description
License number
State
3336L0003X
Long Term Care Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PHY58030
PHARMACY LICENSE
CA
Enumeration date
09/09/2021
Last updated
04/18/2024
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