Healthcare Provider Details

I. General information

NPI: 1467088773
Provider Name (Legal Business Name): IMGRX SJ VALLEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 11/30/2023
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17008 13TH ST. ATTN: PHARMACY
HURON CA
93234-9997
US

IV. Provider business mailing address

13651 DUBLIN CT ATTN: CHC PHARMACY DEPT.
STAFFORD TX
77477-4317
US

V. Phone/Fax

Practice location:
  • Phone: 4-924-2278
  • Fax: 559-942-8016
Mailing address:
  • Phone: 281-749-2547
  • Fax: 614-652-8169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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