Provider Demographics
NPI:1316294598
Name:IMGRX SJ VALLEY, INC.
Entity type:Organization
Organization Name:IMGRX SJ VALLEY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-749-4764
Mailing Address - Street 1:ATTN: CHC RETAIL PHARMACY DEPT. 13651 DUBLIN CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:281-749-4000
Mailing Address - Fax:614-652-0326
Practice Address - Street 1:476 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EARLIMART
Practice Address - State:CA
Practice Address - Zip Code:93219
Practice Address - Country:US
Practice Address - Phone:661-849-2781
Practice Address - Fax:616-849-4005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMGRX SJ VALLEY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-07
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY 545213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy