Provider Demographics
NPI:1700960838
Name:JFK MEDICAL PLAZA PHARMACY INC
Entity type:Organization
Organization Name:JFK MEDICAL PLAZA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-772-7300
Mailing Address - Street 1:41120 WASHINGTON ST
Mailing Address - Street 2:STE 100
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-9215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41120 WASHINGTON ST
Practice Address - Street 2:STE 100
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-9215
Practice Address - Country:US
Practice Address - Phone:760-772-7300
Practice Address - Fax:760-772-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45002333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY45002Medicaid
0544052OtherOTHER ID NUMBER-COMMERCIAL NUMBER