Healthcare Provider Details

I. General information

NPI: 1912922741
Provider Name (Legal Business Name): SAN JOSE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W EULALIA ST STE 212
GLENDALE CA
91204-2851
US

IV. Provider business mailing address

13428 MAXELLA AVE # 193
MARINA DEL REY CA
90292-5620
US

V. Phone/Fax

Practice location:
  • Phone: 818-247-3266
  • Fax: 818-247-3267
Mailing address:
  • Phone: 818-247-3266
  • Fax: 818-247-3267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number24085532
License Number StateCA

VIII. Authorized Official

Name: MISS TONY GALE WALKER
Title or Position: OWNER
Credential: RPH
Phone: 818-247-3266