Provider Demographics
NPI:1184124984
Name:ST. JOSEPH PHARMACY, INC.
Entity type:Organization
Organization Name:ST. JOSEPH PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:ETTEDGUI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:818-259-5375
Mailing Address - Street 1:2519 W BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2302
Mailing Address - Country:US
Mailing Address - Phone:818-736-5290
Mailing Address - Fax:818-736-5276
Practice Address - Street 1:2519 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2302
Practice Address - Country:US
Practice Address - Phone:818-736-5290
Practice Address - Fax:818-736-5276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CA56040333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175758OtherPK