Provider Demographics
NPI:1821239112
Name:GARDNER FAMILY HEALTH NETWORK INC
Entity Type:Organization
Organization Name:GARDNER FAMILY HEALTH NETWORK INC
Other - Org Name:GARDNER SOUTH COUNTY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-918-2613
Mailing Address - Street 1:7526 MONTEREY ST
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5826
Mailing Address - Country:US
Mailing Address - Phone:408-848-9494
Mailing Address - Fax:408-848-9496
Practice Address - Street 1:7526 MONTEREY ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5826
Practice Address - Country:US
Practice Address - Phone:408-848-9494
Practice Address - Fax:408-848-9496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
CA492703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5633816OtherNCPDP PROVIDER IDENTIFICATION NUMBER