Healthcare Provider Details

I. General information

NPI: 1255417374
Provider Name (Legal Business Name): COUNTY OF SANTA CLARA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 N MAIN ST SUITE 1038
MILPITAS CA
95035-4322
US

IV. Provider business mailing address

751 S BASCOM AVE BUILDING W
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-2300
  • Fax: 408-885-5822
Mailing address:
  • Phone: 408-885-2300
  • Fax: 408-885-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHE40474
License Number StateCA

VIII. Authorized Official

Name: DR. ALFONSO F BANUELOS JR.
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 408-885-4001