Provider Demographics
NPI:1699846774
Name:JEFFERSON PHARMACY
Entity type:Organization
Organization Name:JEFFERSON PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEATLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:916-371-2022
Mailing Address - Street 1:1029 JEFFERSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-3344
Mailing Address - Country:US
Mailing Address - Phone:916-371-2022
Mailing Address - Fax:916-371-2027
Practice Address - Street 1:1029 JEFFERSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-3344
Practice Address - Country:US
Practice Address - Phone:916-371-2022
Practice Address - Fax:916-371-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY470833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1821081910Medicaid
2115818OtherPK
5527150001Medicare NSC
CABJ 9319268OtherDEA NUMBER
CARPH 50909OtherPHARMACIST LICENSE #
CA5527150001Medicare ID - Type UnspecifiedCMS IDENTIFIER