Healthcare Provider Details

I. General information

NPI: 1144746348
Provider Name (Legal Business Name): GOOSE PHARMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18049 MAGNOLIA STREET
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

18049 MAGNOLIA ST
FOUNTAIN VALLEY CA
92708-5638
US

V. Phone/Fax

Practice location:
  • Phone: 510-610-1336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number StateCA

VIII. Authorized Official

Name: JENNY DANG
Title or Position: MANAGER
Credential: PHARMD.
Phone: 510-610-1336