Provider Demographics
NPI:1104999119
Name:PACIFIC PHARMACY
Entity type:Organization
Organization Name:PACIFIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HUNG
Authorized Official - Middle Name:VIET
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-937-4618
Mailing Address - Street 1:2874 ALUM ROCK AVE
Mailing Address - Street 2:STE A
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-2804
Mailing Address - Country:US
Mailing Address - Phone:408-937-4618
Mailing Address - Fax:408-937-8371
Practice Address - Street 1:2874 ALUM ROCK AVE
Practice Address - Street 2:STE A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-2804
Practice Address - Country:US
Practice Address - Phone:408-937-4618
Practice Address - Fax:408-937-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47826332B00000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA409030Medicaid
CAPHA409030Medicaid