1386649887 NPI number — ALUM ROCK PHARMACY INC

Table of content: (NPI 1386649887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386649887 NPI number — ALUM ROCK PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALUM ROCK PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALUM ROCK PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386649887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1855 ALUM ROCK AVE
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95116-1398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-254-1551
Provider Business Mailing Address Fax Number:
408-254-3099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1855 ALUM ROCK AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95116-1398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-254-1551
Provider Business Practice Location Address Fax Number:
408-254-3099
Provider Enumeration Date:
06/20/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
AN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER/PIC
Authorized Official Telephone Number:
408-254-1551

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY51450 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2140895 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHY49179 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".