Provider Demographics
NPI:1184052037
Name:EARTH VILLAGE PHARMACY INC
Entity type:Organization
Organization Name:EARTH VILLAGE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-228-9212
Mailing Address - Street 1:5161 BEACH BLVD
Mailing Address - Street 2:UNIT #C
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1171
Mailing Address - Country:US
Mailing Address - Phone:714-228-9212
Mailing Address - Fax:714-228-9217
Practice Address - Street 1:5161 BEACH BLVD
Practice Address - Street 2:UNIT #C
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-1171
Practice Address - Country:US
Practice Address - Phone:714-228-9212
Practice Address - Fax:714-228-9217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-30
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7147750001Medicare NSC