1295805430 NPI number — PHNOM PICH PHARMACY INC

Table of content: (NPI 1295805430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295805430 NPI number — PHNOM PICH PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHNOM PICH 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:
PHNOM PICH PHARMACY INC
Provider Other Organization Name Type Code:
3
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:
1295805430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2338 E ANAHEIM ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90804-5730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-438-3324
Provider Business Mailing Address Fax Number:
562-987-1801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2338 E ANAHEIM ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90804-5730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-438-3324
Provider Business Practice Location Address Fax Number:
562-987-1801
Provider Enumeration Date:
11/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SANUI
Authorized Official First Name:
PUTHIK
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
562-438-3324

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY48907 , 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: 1992188 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHA47330 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".