Healthcare Provider Details

I. General information

NPI: 1942575790
Provider Name (Legal Business Name): ST JOSEPH PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 CHALAN SAN ANTONIO STE 101
TAMUNING GU
96913-3620
US

IV. Provider business mailing address

425 CHALAN SAN ANTONIO # 168
TAMUNING GU
96913-3602
US

V. Phone/Fax

Practice location:
  • Phone: 671-648-1128
  • Fax:
Mailing address:
  • Phone: 671-727-8216
  • Fax:

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 NumberPCY057
License Number StateGU

VIII. Authorized Official

Name: UYEN PHAM
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 671-648-1128