Healthcare Provider Details

I. General information

NPI: 1962504225
Provider Name (Legal Business Name): IMGRX SJ VALLEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 09/20/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S MADERA AVE
KERMAN CA
93630-1523
US

IV. Provider business mailing address

13651 DUBLIN CT
STAFFORD TX
77477-4317
US

V. Phone/Fax

Practice location:
  • Phone: 559-846-6330
  • Fax: 559-842-2370
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 NumberPHY54520
License Number StateCA

VIII. Authorized Official

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