Provider Demographics
NPI:1023029600
Name:MEDICAL TREE PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL TREE PHARMACY INC
Other - Org Name:MEDICAL CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMBASKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-426-0200
Mailing Address - Street 1:2025 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:831-426-0200
Mailing Address - Fax:831-426-0507
Practice Address - Street 1:2025 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1323
Practice Address - Country:US
Practice Address - Phone:831-426-0200
Practice Address - Fax:831-426-0507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY212013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115560OtherPK
CAPHA212010Medicaid