Provider Demographics
NPI:1407122815
Name:DESERT AGAVE PHARMACY INC
Entity Type:Organization
Organization Name:DESERT AGAVE PHARMACY INC
Other - Org Name:DE ANZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:760-768-2900
Mailing Address - Street 1:302 #B E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2760
Mailing Address - Country:US
Mailing Address - Phone:760-768-2900
Mailing Address - Fax:760-768-2929
Practice Address - Street 1:302 #B E 3RD ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2760
Practice Address - Country:US
Practice Address - Phone:760-768-2900
Practice Address - Fax:760-768-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY50893333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY50893OtherCALIFORNIA STATE BOARD OF PHARMACY
CAPHY50893OtherCALIFORNIA STATE BOARD OF PHARMACY