Provider Demographics
NPI:1750315719
Name:GENESIS PHARMACY
Entity Type:Organization
Organization Name:GENESIS PHARMACY
Other - Org Name:NOT APPLICABLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JULLIARD
Authorized Official - Middle Name:ESGUERRA
Authorized Official - Last Name:PARUNGAO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY TECHNICIAN
Authorized Official - Phone:562-920-2300
Mailing Address - Street 1:10504 E. ARTESIA BLVD.
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-6804
Mailing Address - Country:US
Mailing Address - Phone:562-920-2300
Mailing Address - Fax:562-920-2311
Practice Address - Street 1:10504 E. ARTESIA BLVD.
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-6804
Practice Address - Country:US
Practice Address - Phone:562-920-2300
Practice Address - Fax:562-920-2311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 443353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA443350Medicaid