Provider Demographics
NPI:1821446030
Name:JADE PHARMACY INC
Entity Type:Organization
Organization Name:JADE PHARMACY INC
Other - Org Name:JADE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/AO
Authorized Official - Prefix:
Authorized Official - First Name:AN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-792-4742
Mailing Address - Street 1:34460 FREMONT BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-3324
Mailing Address - Country:US
Mailing Address - Phone:510-792-4742
Mailing Address - Fax:510-792-4745
Practice Address - Street 1:34460 FREMONT BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94555-3324
Practice Address - Country:US
Practice Address - Phone:510-792-4742
Practice Address - Fax:510-792-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA543693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160340OtherPK