Provider Demographics
NPI:1740326784
Name:MOWRY MEDICAL PHARMACY, INC.
Entity type:Organization
Organization Name:MOWRY MEDICAL PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASRAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-793-5011
Mailing Address - Street 1:1999 MOWRY AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1738
Mailing Address - Country:US
Mailing Address - Phone:510-793-5011
Mailing Address - Fax:510-792-9599
Practice Address - Street 1:1999 MOWRY AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1738
Practice Address - Country:US
Practice Address - Phone:510-793-5011
Practice Address - Fax:510-792-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY211383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45674OtherSTATE BOARD OF PHARMACY LICENSE
CAPHA211380Medicaid