Provider Demographics
NPI:1689700080
Name:TULLY CLINIC PHARMACY
Entity Type:Organization
Organization Name:TULLY CLINIC PHARMACY
Other - Org Name:TULLY MEDICAL CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAI
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-274-6698
Mailing Address - Street 1:1693 FLANIGAN DR
Mailing Address - Street 2:STE 104
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1683
Mailing Address - Country:US
Mailing Address - Phone:408-274-6698
Mailing Address - Fax:408-274-8580
Practice Address - Street 1:1693 FLANIGAN DR
Practice Address - Street 2:STE 104
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1683
Practice Address - Country:US
Practice Address - Phone:408-274-6698
Practice Address - Fax:408-274-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY357543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0598536OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA357540Medicaid
CAPHA357540Medicaid