Waterfront Pharmacy LTC LLC

Primary specialty

Long Term Care PharmacyTaxonomy code 3336L0003X

Legal business name

WATERFRONT PHARMACY LTC LLC

Practice address

123 S Commerce St Ste a
Stockton, CA 95202-2837

Phone

(209) 298-1715

Fax

(559) 369-2408

NPI assigned

Sep 9, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Chandra Kadiyala

Title

Ceo

Phone

(509) 392-1958

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CA2 enrollments

Enrollment records 2

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1631145600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713398400000",
    "number": "1114696382",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "123 S COMMERCE ST STE A",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952022837",
            "telephone_number": "209-929-1093",
            "fax_number": "209-929-1096"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "123 S COMMERCE ST STE A",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952022837",
            "telephone_number": "209-298-1715",
            "fax_number": "559-369-2408"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATERFRONT PHARMACY LTC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-09-09",
        "last_updated": "2024-04-18",
        "certification_date": "2024-04-18",
        "status": "A",
        "authorized_official_last_name": "KADIYALA",
        "authorized_official_first_name": "CHANDRA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "509-392-1958",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHARMACY LICENSE",
            "identifier": "PHY58030",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kerry Washington, RNC
• Lorraine McGahee Washington
• Quwiala Washington, MFTI
• Thombelina Washington, BSN,RN, PHN
• Wayne Allen Washington, SUDCC III
• Erica R Waters, M.D.
• Gregory Allen Waters
• Paul A Waters, MD
• Waterways Health Care Center
• Donald David Watkins, LCSW

• Long Term Care Pharmacy in Stockton, CA
• Providers in Stockton, CA by specialty
• Long Term Care Pharmacy in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.