Provider Demographics
NPI:1629490412
Name:CASTALDO, JACK (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CASTALDO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-3627
Mailing Address - Country:US
Mailing Address - Phone:650-948-1212
Mailing Address - Fax:
Practice Address - Street 1:255 2ND ST
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-3627
Practice Address - Country:US
Practice Address - Phone:650-948-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist