1255422085 NPI number — LAX PHARMACY INC

Table of content: (NPI 1255422085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255422085 NPI number — LAX PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAX 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:
1255422085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4457 LENNOX BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENNOX
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90304-2303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-674-1403
Provider Business Mailing Address Fax Number:
310-674-1421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4457 LENNOX BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENNOX
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90304-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-674-1403
Provider Business Practice Location Address Fax Number:
310-674-1421
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AHDOUT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-674-1403

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY48895 , 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: 1255422085 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0594730 . This is a "NCPDP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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