1417978461 NPI number — HERBERT A GLICKSMAN

Table of content: (NPI 1417978461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417978461 NPI number — HERBERT A GLICKSMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERBERT A GLICKSMAN
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:
6
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:
1417978461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9001 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90211-1838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-859-3887
Provider Business Mailing Address Fax Number:
310-859-3454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9001 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90211-1838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-859-3887
Provider Business Practice Location Address Fax Number:
310-859-3454
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLICKSMAN
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
310-859-3887

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY34171 , 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: PHA341710 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1998943 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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