Provider Demographics
NPI:1497814594
Name:JAFA PHARMACEUTICALS, INC.
Entity Type:Organization
Organization Name:JAFA PHARMACEUTICALS, INC.
Other - Org Name:CREEKSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-987-6796
Mailing Address - Street 1:95 MONTGOMERY DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6630
Mailing Address - Country:US
Mailing Address - Phone:707-525-1130
Mailing Address - Fax:707-525-8099
Practice Address - Street 1:95 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-525-1130
Practice Address - Fax:707-525-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY556153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126477OtherPK