Healthcare Provider Details

I. General information

NPI: 1669105540
Provider Name (Legal Business Name): JOSE GRANDE JR. PHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 W EDINGER AVE
SANTA ANA CA
92704-4307
US

IV. Provider business mailing address

1406 W EDINGER AVE
SANTA ANA CA
92704-4307
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-6191
  • Fax: 714-546-5037
Mailing address:
  • Phone: 714-546-6191
  • Fax: 714-546-5037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number104218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: