1417231630 NPI number — KING'S PHARMACY AND COMPOUNDING CENTER

Table of content: (NPI 1417231630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417231630 NPI number — KING'S PHARMACY AND COMPOUNDING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING'S PHARMACY AND COMPOUNDING CENTER
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:
KING'S PHARMACY AND COMPOUNDING CENTER
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:
1417231630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 SUPERIOR AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92663-3663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-631-4624
Provider Business Mailing Address Fax Number:
949-631-4626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 SUPERIOR AVE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92663-3665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-631-4624
Provider Business Practice Location Address Fax Number:
949-631-4626
Provider Enumeration Date:
10/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
REZAEI
Authorized Official First Name:
ALI
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC/OWNER
Authorized Official Telephone Number:
949-244-9415

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY50750 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2132199 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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