Provider Demographics
NPI:1790863991
Name:COUNTY OF SANTA CLARA
Entity Type:Organization
Organization Name:COUNTY OF SANTA CLARA
Other - Org Name:VALLEY HEALTH CENTER AT TULLY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:F
Authorized Official - Last Name:BANUELOS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:408-885-4001
Mailing Address - Street 1:751 S BASCOM AVE
Mailing Address - Street 2:BUILDING W
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2604
Mailing Address - Country:US
Mailing Address - Phone:408-885-2300
Mailing Address - Fax:408-885-5822
Practice Address - Street 1:500 TULLY RD
Practice Address - Street 2:VHC AT TULLY PHARMACY
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1917
Practice Address - Country:US
Practice Address - Phone:408-817-1360
Practice Address - Fax:408-817-1367
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SANTA CLARA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-02
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE30090333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHB300900Medicaid
CA0518879Medicare PIN
CAPHB300900Medicaid