Provider Demographics
NPI:1134119977
Name:NEW TIBURCIO VASQUEZ HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:NEW TIBURCIO VASQUEZ HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:KAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:510-813-8687
Mailing Address - Street 1:33225 9TH ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-2137
Mailing Address - Country:US
Mailing Address - Phone:510-489-8088
Mailing Address - Fax:510-489-1811
Practice Address - Street 1:33225 9TH ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-2137
Practice Address - Country:US
Practice Address - Phone:510-489-8088
Practice Address - Fax:510-489-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY395063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA395060Medicaid