Healthcare Provider Details

I. General information

NPI: 1083786867
Provider Name (Legal Business Name): ENTAG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 E MAIN ST STE 101
EL CAJON CA
92021-5225
US

IV. Provider business mailing address

1685 E MAIN ST STE 101
EL CAJON CA
92021-5225
US

V. Phone/Fax

Practice location:
  • Phone: 619-383-2757
  • Fax: 619-956-3136
Mailing address:
  • Phone: 619-383-2757
  • Fax: 858-429-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHY49784
License Number StateCA

VIII. Authorized Official

Name: MOHAMMAD FATHIE
Title or Position: CFO
Credential:
Phone: 619-200-3927