Provider Demographics
NPI:1043099328
Name:SAN JOSE CLINIC
Entity type:Organization
Organization Name:SAN JOSE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ CHIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-758-6046
Mailing Address - Street 1:2615 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-9224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 LANE DR STE 31
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-2263
Practice Address - Country:US
Practice Address - Phone:832-945-6244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JOSE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy