Provider Demographics
NPI:1538166384
Name:JGS PHARMACIES INC
Entity type:Organization
Organization Name:JGS PHARMACIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V.P., OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTTORMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-575-1313
Mailing Address - Street 1:1055 W COLLEGE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5059
Mailing Address - Country:US
Mailing Address - Phone:707-575-1313
Mailing Address - Fax:707-575-0104
Practice Address - Street 1:1055 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5059
Practice Address - Country:US
Practice Address - Phone:707-575-1313
Practice Address - Fax:707-575-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
CAPHY459363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005225OtherPK
CAPHA429030Medicaid
CAPHA429030Medicaid