Provider Demographics
NPI:1295837003
Name:SAN JUAN PHARMACY
Entity Type:Organization
Organization Name:SAN JUAN PHARMACY
Other - Org Name:SAN JUAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-493-4559
Mailing Address - Street 1:31901 CAMINO CAPISTRANO
Mailing Address - Street 2:SUITE #8
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3238
Mailing Address - Country:US
Mailing Address - Phone:949-493-4559
Mailing Address - Fax:949-493-8247
Practice Address - Street 1:31901 CAMINO CAPISTRANO
Practice Address - Street 2:SUITE #8
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3238
Practice Address - Country:US
Practice Address - Phone:949-493-4559
Practice Address - Fax:949-493-8247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X, 333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA410280Medicaid
CA1072260001Medicare ID - Type UnspecifiedPHARMACY AND DURABLE MEDI