Provider Demographics
NPI:1053346890
Name:ABORN PHARMACY
Entity type:Organization
Organization Name:ABORN PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANG CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-644-7158
Mailing Address - Street 1:2060 ABORN RD
Mailing Address - Street 2:STE 150B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1584
Mailing Address - Country:US
Mailing Address - Phone:408-531-1899
Mailing Address - Fax:408-238-3978
Practice Address - Street 1:2060 ABORN RD
Practice Address - Street 2:STE 150B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1584
Practice Address - Country:US
Practice Address - Phone:408-531-1899
Practice Address - Fax:408-238-3978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY431663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2002316OtherPK
CAPHA431660Medicaid