MEDICARE: FAMILY 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	3336C0003X	Community/Retail Pharmacy	PHY49083	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740262914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PHARMACY, INC.

Provider Business Mailing Address
First Line	:	1033 N WATERMAN AVE
Second Line	:	STE C
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-3823
Country	:	US
Telephone Number	:	909-884-2739
Fax Number	:	909-885-8880

Provider Business Practice Location Address
First Line	:	1033 N WATERMAN AVE
Second Line	:	STE C
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-3823
Country	:	US
Telephone Number	:	909-884-2739
Fax Number	:	909-885-8880

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. NGUYEN DUC DAO
Credential	:	PHARM D
Telephone Number	:	909-884-2739

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	03/23/2017

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