Provider Demographics
NPI:1396756805
Name:SOUTH GATE ROSE PHCY INC
Entity type:Organization
Organization Name:SOUTH GATE ROSE PHCY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-350-3009
Mailing Address - Street 1:8615 KNOTT AVE
Mailing Address - Street 2:STE 7
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8615 KNOTT AVE
Practice Address - Street 2:STE 7
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3841
Practice Address - Country:US
Practice Address - Phone:714-952-4978
Practice Address - Fax:714-953-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY476053336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5622990OtherOTHER ID NUMBER-COMMERCIAL NUMBER