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General NPI Number Information
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NPI Number | 1407122815
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Entity Type | Organization
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Legal Business Name | DESERT AGAVE PHARMACY INC
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Dates
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Enumeration Date | 03/29/2012
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 302 #B E 3RD ST
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City | CALEXICO
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State | CA
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Zip | 92231-2760
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Country | US
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Telephone | 760-768-2900
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Fax | 760-768-2929
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Provider Business Mailing Address
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Address Line | 302 #B E 3RD ST
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City | CALEXICO
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State | CA
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Zip | 92231-2760
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Country | US
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Telephone | 760-768-2900
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Fax | 760-768-2929
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Authorized Official
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Title or Position | PRESIDENT/PIC
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Name | DR. GREGORY GELMAN
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Credential | PHARM D
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Telephone | 760-768-2900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | PHY50893
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY50893
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License Number State | CA
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