Provider Demographics
NPI:1992020028
Name:JACKSON LTC PHARMACY INC.
Entity Type:Organization
Organization Name:JACKSON LTC PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:KATPELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-464-9777
Mailing Address - Street 1:266 N JACKSON AVE
Mailing Address - Street 2:8B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 N JACKSON AVE
Practice Address - Street 2:8B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1606
Practice Address - Country:US
Practice Address - Phone:408-251-7009
Practice Address - Fax:404-251-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy