Healthcare Provider Details

I. General information

NPI: 1962540955
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: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 N MARINE CORPS DR
TAMUNING GU
96913-4308
US

IV. Provider business mailing address

1244 N MARINE CORPS DR
TAMUNING GU
96913-4308
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-6515
  • Fax: 671-646-6516
Mailing address:
  • Phone: 671-646-6515
  • Fax: 671-646-6516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY042
License Number StateGU

VIII. Authorized Official

Name: MARILYN FLORENDO
Title or Position: MANAGING PHARMACIST
Credential: RPH
Phone: 671-646-6515