Provider Demographics
NPI:1003235144
Name:PHARMATEK PHARMACY INC
Entity Type:Organization
Organization Name:PHARMATEK PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAHVASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANBASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-553-6462
Mailing Address - Street 1:1529 REXFORD DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10995 N 99TH AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5405
Practice Address - Country:US
Practice Address - Phone:928-583-4781
Practice Address - Fax:877-513-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY005901333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZY005901OtherPHARMACY LICENSE