Provider Demographics
NPI:1083786867
Name:ENTAG INC
Entity Type:Organization
Organization Name:ENTAG INC
Other - Org Name:MEDICINE CARE PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FATHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-200-3927
Mailing Address - Street 1:1685 E MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5225
Mailing Address - Country:US
Mailing Address - Phone:619-383-2757
Mailing Address - Fax:858-429-5780
Practice Address - Street 1:1685 E MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5225
Practice Address - Country:US
Practice Address - Phone:619-383-2757
Practice Address - Fax:619-956-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CAPHY497843336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA433180Medicaid
2001246OtherPK
CA3354331Medicaid
2001246OtherPK