Provider Demographics
NPI:1487949319
Name:ENTAG INC
Entity type:Organization
Organization Name:ENTAG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEHROOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHZADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-892-0136
Mailing Address - Street 1:1685 E MAIN ST
Mailing Address - Street 2:#103
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5225
Mailing Address - Country:US
Mailing Address - Phone:619-401-7077
Mailing Address - Fax:619-951-3136
Practice Address - Street 1:1685 E MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5225
Practice Address - Country:US
Practice Address - Phone:619-401-7077
Practice Address - Fax:619-951-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
CAPHY506693336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130689OtherPK