Healthcare Provider Details

I. General information

NPI: 1104999119
Provider Name (Legal Business Name): PACIFIC PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2874 ALUM ROCK AVE STE A
SAN JOSE CA
95127-2804
US

IV. Provider business mailing address

2874 ALUM ROCK AVE STE A
SAN JOSE CA
95127-2804
US

V. Phone/Fax

Practice location:
  • Phone: 408-937-4618
  • Fax: 408-937-8371
Mailing address:
  • Phone: 408-937-4618
  • Fax: 408-937-8371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47826
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number47826
License Number StateCA

VIII. Authorized Official

Name: MR. HUNG VIET NGUYEN
Title or Position: OWNER
Credential:
Phone: 408-937-4618