Provider Demographics
NPI:1154327302
Name:TIFFANY THU INC
Entity Type:Organization
Organization Name:TIFFANY THU INC
Other - Org Name:KING PHARMACY AND DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-347-0193
Mailing Address - Street 1:2323 MONTPELIER DR
Mailing Address - Street 2:STE D
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1611
Mailing Address - Country:US
Mailing Address - Phone:408-347-0193
Mailing Address - Fax:408-347-0293
Practice Address - Street 1:2323 MONTPELIER DR
Practice Address - Street 2:STE D
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1611
Practice Address - Country:US
Practice Address - Phone:408-347-0193
Practice Address - Fax:408-347-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY451983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992447OtherPK
CAPHA451980Medicaid
5528510001Medicare NSC