=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972615086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL PLAZA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 05/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 QUARRY RD STE 108
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94304-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-326-2300
-----------------------------------------------------
Fax | 650-326-2351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 INDUSTRIAL RD
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-412-4555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | JONATHAN HAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-412-4555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY45166
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------