Provider Demographics
NPI:1972615086
Name:MEDICAL PLAZA PHARMACY INC
Entity type:Organization
Organization Name:MEDICAL PLAZA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-412-4555
Mailing Address - Street 1:420 INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-6286
Mailing Address - Country:US
Mailing Address - Phone:650-412-4555
Mailing Address - Fax:
Practice Address - Street 1:211 QUARRY RD STE 108
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1416
Practice Address - Country:US
Practice Address - Phone:650-326-2300
Practice Address - Fax:650-326-2351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
CAPHY451663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997900OtherPK
CAPHY45166Medicaid
0851590001Medicare NSC