Provider Demographics
NPI:1700958584
Name:JDUB PHARMA
Entity Type:Organization
Organization Name:JDUB PHARMA
Other - Org Name:THE MEDICINE SHOPPE #387
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:VARELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-648-2724
Mailing Address - Street 1:2611 E THOMPSON BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2743
Mailing Address - Country:US
Mailing Address - Phone:805-648-2724
Mailing Address - Fax:805-648-7562
Practice Address - Street 1:2611 E THOMPSON BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-648-2724
Practice Address - Fax:805-648-7562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY561143336C0003X
CAPHY431263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0582189OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CA1700958584Medicaid
CA1700958584Medicaid
CABT5548562OtherDEA #