Provider Demographics
NPI:1982788170
Name:SAN JOAQUIN DRUG INCORPORATED
Entity Type:Organization
Organization Name:SAN JOAQUIN DRUG INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:209-382-1291
Mailing Address - Street 1:9215 EAST HIGHWAY 140
Mailing Address - Street 2:PO BOX 1636
Mailing Address - City:PLANADA
Mailing Address - State:CA
Mailing Address - Zip Code:95365-1636
Mailing Address - Country:US
Mailing Address - Phone:209-382-1291
Mailing Address - Fax:
Practice Address - Street 1:9215 EAST HIGHWAY 140
Practice Address - Street 2:
Practice Address - City:PLANADA
Practice Address - State:CA
Practice Address - Zip Code:95365-1636
Practice Address - Country:US
Practice Address - Phone:209-382-1291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
CAPHA464683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0555550OtherNCPDP
CAPHY46468OtherCA PHARMACY LICENSE
CAPHA447650OtherMEDI-CAL
CABS6796998OtherDEA REGISTRATON
CAPHA447650OtherMEDI-CAL