1265502496 NPI number — ST LUKE PHARMACY INC

Table of content: (NPI 1265502496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265502496 NPI number — ST LUKE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKE PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265502496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16660 PARAMOUNT BLVD STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARAMOUNT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90723-5457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-220-2630
Provider Business Mailing Address Fax Number:
562-220-2649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16402 PARAMOUNT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARAMOUNT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90723-5428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-220-2793
Provider Business Practice Location Address Fax Number:
562-220-2753
Provider Enumeration Date:
11/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SALIBA
Authorized Official First Name:
SHUKRI
Authorized Official Middle Name:
FUAD
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
562-220-2630

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PHY44640 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA446400 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".