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General NPI Number Information
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NPI Number | 1265795447
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Entity Type | Organization
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Legal Business Name | 4TH STREET PHARMACY, INC
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Dates
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Enumeration Date | 06/21/2012
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 1765 4TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92101-2670
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Country | US
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Telephone | 619-398-1800
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Fax | 619-481-3733
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Provider Business Mailing Address
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Address Line | 1765 4TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92101-2670
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Country | US
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Telephone | 619-398-1800
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Fax | 619-481-3733
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Authorized Official
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Title or Position | OWNER/PIC
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Name | MR. JOSEPH GRASELA
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Credential | RPH
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Telephone | 619-683-2005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 50831
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License Number State | CA
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