Provider Demographics
NPI:1053835595
Name:STANFORD HEALTH CARE
Entity Type:Organization
Organization Name:STANFORD HEALTH CARE
Other - Org Name:STANFORD HEALTH CARE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, PHARMACY SERVICES-SPECIAL
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:650-736-3800
Mailing Address - Street 1:875 BLAKE WILBUR DR STE CC1102
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-2205
Mailing Address - Country:US
Mailing Address - Phone:650-736-3800
Mailing Address - Fax:650-736-7991
Practice Address - Street 1:875 BLAKE WILBUR DR STE CC1102
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2205
Practice Address - Country:US
Practice Address - Phone:650-736-3800
Practice Address - Fax:650-736-7991
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STANFORD HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA554823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170491OtherPK
CAPENDINGMedicaid