Provider Demographics
NPI:1023152071
Name:CRUZ PHARMACY
Entity type:Organization
Organization Name:CRUZ PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:HEE
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:671-646-5556
Mailing Address - Street 1:224 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3208
Mailing Address - Country:US
Mailing Address - Phone:671-646-5556
Mailing Address - Fax:671-649-0469
Practice Address - Street 1:224 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3208
Practice Address - Country:US
Practice Address - Phone:671-646-5556
Practice Address - Fax:671-649-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPCY013333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU5447550001Medicare NSC