Fortuna Pharmacy Inc
Organization Active NPI Community/Retail Pharmacy · Fortuna, CA
NPI 1881806610 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1881806610
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- PHY37268 (CA)
- Legal business name
- FORTUNA PHARMACY INC
- Practice address
- 1058 Main St
Fortuna, CA 95540-2009 - Phone
- (707) 725-4431
- Fax
- (707) 725-2671
- NPI assigned
- May 4, 2007
- Organization subpart
- No
Authorized official
- Name
- Robert Earl Johnson, RPH
- Title
- President
- Phone
- (707) 725-4431
Practitioners 1
-
Robert Earl Johnson, RPH
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D2316599 | Fortuna Pharmacy Inc | Certificate of waiver | Jan 7, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20120803000616 | CA | Part B Supplier - Mass Immunization (Roster Biller Only) | 1355460247 | Practice locations: Fortuna, CA |
National Provider Directory
Locations
906 Main St
Fortuna, CA 95540
Phone (707) 725-4431
1058 Main St
Fortuna, CA 95540
Phone (707) 725-4431
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | PHY37268 | CA | Yes |
Addresses
Primary practice location
1058 Main St
Fortuna, CA 95540-2009
Mailing address
1058 Main St
Fortuna, CA 95540-2009
Phone (707) 725-4431
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| PHA372680 | Medicaid | CA |
Other names
- GREEN'S FORTUNA PHARMACY
Other providers in Fortuna, CA
- Fortuna Assisted Living LLC
- Fortuna Chiropractic LLC
- Fortuna Elementary School District
- Fortuna Family Medical Group Inc
- Fortuna Family Medicine Inc.
- Fortuna Rehabilitation & Wellness Center, LP
- Fortuna Union High School
- Tatsiana Franco
- Maureen B Frank
- Joy Nadine Frasier
All providers in Fortuna, CA · Community/Retail Pharmacy in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.