Provider Demographics
NPI:1164167896
Name:SAN JOSE PHARMACY INC
Entity Type:Organization
Organization Name:SAN JOSE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-642-4904
Mailing Address - Street 1:8424 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7339
Mailing Address - Country:US
Mailing Address - Phone:347-642-4904
Mailing Address - Fax:
Practice Address - Street 1:8424 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7339
Practice Address - Country:US
Practice Address - Phone:347-642-4904
Practice Address - Fax:347-531-0739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy