Healthcare Provider Details

I. General information

NPI: 1669019113
Provider Name (Legal Business Name): SHANZO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 11/17/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 UNIVERSITY AVE STE A1
SAN DIEGO CA
92115-5727
US

IV. Provider business mailing address

PO BOX 504123
SAN DIEGO CA
92150-4123
US

V. Phone/Fax

Practice location:
  • Phone: 619-436-5571
  • Fax: 619-436-5572
Mailing address:
  • Phone: 619-436-5571
  • Fax: 619-436-5572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN HAN
Title or Position: CEO
Credential:
Phone: 619-436-5571