Provider Demographics
NPI:1225174832
Name:GEORGE JABER MICHAEL JABER & PHILLIP JABER PTR
Entity Type:Organization
Organization Name:GEORGE JABER MICHAEL JABER & PHILLIP JABER PTR
Other - Org Name:VERSAILLES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:JABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-523-4907
Mailing Address - Street 1:2801 ENCINAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4726
Mailing Address - Country:US
Mailing Address - Phone:510-523-4907
Mailing Address - Fax:510-523-4580
Practice Address - Street 1:2801 ENCINAL AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4726
Practice Address - Country:US
Practice Address - Phone:510-523-4907
Practice Address - Fax:510-523-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY227103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA227100Medicaid
2002896OtherPK