Provider Demographics
NPI:1669583993
Name:TJ ENTERPRISES, INC.
Entity type:Organization
Organization Name:TJ ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:CHANGKI
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:626-960-4723
Mailing Address - Street 1:1135 S SUNSET AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3938
Mailing Address - Country:US
Mailing Address - Phone:626-960-4723
Mailing Address - Fax:626-813-7648
Practice Address - Street 1:1135 S SUNSET AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3938
Practice Address - Country:US
Practice Address - Phone:626-960-4723
Practice Address - Fax:626-813-7648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30026333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA455710Medicaid
CA1669583993Medicaid
CA1014040002Medicare NSC