Healthcare Provider Details

I. General information

NPI: 1710087887
Provider Name (Legal Business Name): IMGRX SJ VALLEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/19/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17008 13TH ST. PHARMACY SUITE
HURON CA
93234
US

IV. Provider business mailing address

ATTN: CHC RETAIL PHARMACY DEPT. 13651 DUBLIN CT
STAFFORD TX
77477
US

V. Phone/Fax

Practice location:
  • Phone: 559-945-2541
  • Fax: 559-942-8016
Mailing address:
  • Phone: 281-749-4000
  • Fax: 614-652-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number54516
License Number StateCA

VIII. Authorized Official

Name: MICHAEL BROWN
Title or Position: VICE PRESIDENT, MANAGED SERVICES
Credential:
Phone: 281-749-4764