Provider Demographics
NPI:1972645273
Name:WOODSIDE VILLAGE PHARMACY
Entity Type:Organization
Organization Name:WOODSIDE VILLAGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:650-851-1131
Mailing Address - Street 1:3048 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2551
Mailing Address - Country:US
Mailing Address - Phone:650-851-1131
Mailing Address - Fax:650-851-8613
Practice Address - Street 1:3048 WOODSIDE RD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-2551
Practice Address - Country:US
Practice Address - Phone:650-851-1131
Practice Address - Fax:650-851-8613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY397943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy