MEDICARE: WHITE HOUSE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0004X	Compounding Pharmacy	PHY54957	CA
2	3336C0003X	Community/Retail Pharmacy	PHY54957	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHY 54957	OTHER	CA	BOARD OF PHARMACY PERMIT

General Provider Information

NPI Number	:	1245787688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE HOUSE PHARMACY INC

Provider Business Mailing Address
First Line	:	2453 FOREST AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-1505
Country	:	US
Telephone Number	:	408-296-5015
Fax Number	:	408-248-2790

Provider Business Practice Location Address
First Line	:	2453 FOREST AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-1505
Country	:	US
Telephone Number	:	408-296-5015
Fax Number	:	408-248-2790

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MR. PATRICK J D'ANGELO
Credential	:
Telephone Number	:	408-296-5015

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	10/05/2016

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Directions to “WHITE HOUSE PHARMACY INC ” Practice Location

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