Provider Demographics
NPI:1164558797
Name:JOSE R SARDINAS
Entity Type:Organization
Organization Name:JOSE R SARDINAS
Other - Org Name:PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SARDINAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:310-973-5200
Mailing Address - Street 1:11930 HAWTHORNE BLV
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:310-973-5200
Mailing Address - Fax:310-973-1243
Practice Address - Street 1:11930 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3016
Practice Address - Country:US
Practice Address - Phone:310-973-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY202593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHA202590OtherMEDICAL
0566589OtherTAX 028418
0566589OtherTAX 028418
PHA202590OtherMEDICAL