MEDICARE: SANTA CLARA DRUG

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	3336S0011X	Specialty Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY39079	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
2	0548531	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1750392338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA CLARA DRUG

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

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
Name	:	LOUISE GIBINO
Credential	:
Telephone Number	:	408-296-5015

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	05/28/2009

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Directions to “SANTA CLARA DRUG ” Practice Location

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