Provider Demographics
NPI:1457463374
Name:BASCOM PHARMACY LLC
Entity Type:Organization
Organization Name:BASCOM PHARMACY LLC
Other - Org Name:BASCOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLIVE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:408-995-6020
Mailing Address - Street 1:105 N BASCOM AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1811
Mailing Address - Country:US
Mailing Address - Phone:408-995-6020
Mailing Address - Fax:408-995-5320
Practice Address - Street 1:105 N BASCOM AVE
Practice Address - Street 2:STE 101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1811
Practice Address - Country:US
Practice Address - Phone:408-995-6020
Practice Address - Fax:408-995-5320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
CA471473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA471470Medicaid
2113723OtherPK
CA5993930001Medicaid