Provider Demographics
NPI:1154775864
Name:SIRUM CHARITABLE PHARMACY
Entity type:Organization
Organization Name:SIRUM CHARITABLE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER & DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-488-7434
Mailing Address - Street 1:150 ALMA ST APT 116
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3748
Mailing Address - Country:US
Mailing Address - Phone:650-488-7434
Mailing Address - Fax:
Practice Address - Street 1:334 SE 5TH AVE STE B
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4107
Practice Address - Country:US
Practice Address - Phone:503-648-0782
Practice Address - Fax:844-238-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCP-0000014333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159403OtherPK