Provider Demographics
NPI:1366598161
Name:HALLERS LTC PHARMACY, INC.
Entity type:Organization
Organization Name:HALLERS LTC PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AARONDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:BASRAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-793-5096
Mailing Address - Street 1:4067 PERALTA BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4849
Mailing Address - Country:US
Mailing Address - Phone:510-793-5096
Mailing Address - Fax:510-745-9950
Practice Address - Street 1:4067 PERALTA BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4849
Practice Address - Country:US
Practice Address - Phone:510-793-5096
Practice Address - Fax:510-745-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X
CA469943336S0011X
CAPHY469943336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Single Specialty
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46994OtherBOARD OF PHARMACY PERMIT
CAPHA469940Medicaid