1033678248 NPI number — KOAM PHARMACY LTC INC

Table of content: DR. MICHELLE BLOCH KATZMAN DDS (NPI 1922183383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033678248 NPI number — KOAM PHARMACY LTC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOAM PHARMACY LTC 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:
1033678248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18102 PIONEER BLVD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARTESIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90701-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-402-4922
Provider Business Mailing Address Fax Number:
562-402-0671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18102 PIONEER BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARTESIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90701-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-402-0400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
KWANG
Authorized Official Middle Name:
JA
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
562-402-4922

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1033678248 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".