Provider Demographics
NPI:1912559162
Name:SAN JOAQUIN DRUG INCORPORATED
Entity Type:Organization
Organization Name:SAN JOAQUIN DRUG INCORPORATED
Other - Org Name:YOSEMITE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:209-484-8184
Mailing Address - Street 1:PO BOX 1636
Mailing Address - Street 2:
Mailing Address - City:PLANADA
Mailing Address - State:CA
Mailing Address - Zip Code:95365
Mailing Address - Country:US
Mailing Address - Phone:209-382-1291
Mailing Address - Fax:
Practice Address - Street 1:35300 HWY 41 SUITE 101
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614
Practice Address - Country:US
Practice Address - Phone:559-692-2479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JOAQUIN DRUG INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-09
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy