Healthcare Provider Details

I. General information

NPI: 1457463374
Provider Name (Legal Business Name): BASCOM PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N BASCOM AVE STE 101
SAN JOSE CA
95128-1811
US

IV. Provider business mailing address

105 N BASCOM AVE STE 101
SAN JOSE CA
95128-1811
US

V. Phone/Fax

Practice location:
  • Phone: 408-995-6020
  • Fax: 408-995-5320
Mailing address:
  • Phone: 408-995-6020
  • Fax: 408-995-5320

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 Number47147
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CLIVE FULLER
Title or Position: MANAGER
Credential: PHARMD
Phone: 408-995-6020