Provider Demographics
NPI:1679016018
Name:ELK GROVE PHARMACY INC
Entity Type:Organization
Organization Name:ELK GROVE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-239-9622
Mailing Address - Street 1:8470 ELK GROVE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5925
Mailing Address - Country:US
Mailing Address - Phone:916-667-3852
Mailing Address - Fax:916-896-5194
Practice Address - Street 1:8470 ELK GROVE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5925
Practice Address - Country:US
Practice Address - Phone:408-239-9622
Practice Address - Fax:916-896-5194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-01
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA552643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166808OtherPK