Provider Demographics
NPI:1336221910
Name:VAN PHARMACY
Entity Type:Organization
Organization Name:VAN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VAN
Authorized Official - Middle Name:THI HONG
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-478-9868
Mailing Address - Street 1:4502 N PERSHING AVE
Mailing Address - Street 2:#AB
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-478-9868
Mailing Address - Fax:209-478-6930
Practice Address - Street 1:4502 N PERSHING AVE
Practice Address - Street 2:#AB
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207
Practice Address - Country:US
Practice Address - Phone:209-478-9868
Practice Address - Fax:209-478-6930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY41834333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA418340Medicaid
RPH43745OtherPHARMACIST
PHY41834OtherPHARMACY
CA5559710001Medicare NSC