Healthcare Provider Details

I. General information

NPI: 1548397128
Provider Name (Legal Business Name): JAKE ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 CHALAN PASAHERU STE C
TAMUNING GU
96913-4161
US

IV. Provider business mailing address

177 CHALAN PASAHERU STE C
TAMUNING GU
96913-4161
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-6160
  • Fax: 671-646-6159
Mailing address:
  • Phone: 671-646-6160
  • Fax: 671-646-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPCY039
License Number StateGU
# 2
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: 671-646-6160