Provider Demographics
NPI:1699357335
Name:JEFFERSON PHARMACY
Entity Type:Organization
Organization Name:JEFFERSON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEATLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:209-938-9556
Mailing Address - Street 1:1029 JEFFERSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-3389
Mailing Address - Country:US
Mailing Address - Phone:916-371-2022
Mailing Address - Fax:916-371-2027
Practice Address - Street 1:1029 JEFFERSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-3389
Practice Address - Country:US
Practice Address - Phone:916-371-2022
Practice Address - Fax:916-371-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1691699846774Medicaid