Healthcare Provider Details

I. General information

NPI: 1841338506
Provider Name (Legal Business Name): JAKE ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 W MARINE CORPS DR STE 8 CALVO'S BLDG
DEDEDO GU
96929-5629
US

IV. Provider business mailing address

612 W MARINE CORPS DR STE 8 CALVO'S BLDG
DEDEDO GU
96929-5629
US

V. Phone/Fax

Practice location:
  • Phone: 671-637-3323
  • Fax: 671-637-3316
Mailing address:
  • Phone: 671-637-3323
  • Fax: 671-637-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPCY046
License Number StateGU
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JUNE AGGABAO
Title or Position: OWNER PRES AND MANAGING PHARM
Credential: RPH
Phone: 671-646-6515