Provider Demographics
NPI:1902056732
Name:HEALTHMARK PHARMACY, INC.
Entity Type:Organization
Organization Name:HEALTHMARK PHARMACY, INC.
Other - Org Name:SAN JOSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEONG HO
Authorized Official - Middle Name:
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-247-3266
Mailing Address - Street 1:222 W. EULALIA STREET
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204
Mailing Address - Country:US
Mailing Address - Phone:818-247-3266
Mailing Address - Fax:818-247-3267
Practice Address - Street 1:222 W. EULALIA STREET
Practice Address - Street 2:SUITE 212
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204
Practice Address - Country:US
Practice Address - Phone:818-247-3266
Practice Address - Fax:818-247-3267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY559193336C0003X
CAPHY491683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117486OtherPK
CA1902056732Medicaid