Provider Demographics
NPI:1013008630
Name:CENTURY BEVERLY HILLS PHARMACY INC
Entity Type:Organization
Organization Name:CENTURY BEVERLY HILLS PHARMACY INC
Other - Org Name:CENTURY BEVERLY HILLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAVOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHDADNIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-360-1015
Mailing Address - Street 1:412 S SAN VICENTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:310-360-1015
Mailing Address - Fax:310-360-0759
Practice Address - Street 1:412 S SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4108
Practice Address - Country:US
Practice Address - Phone:310-360-1015
Practice Address - Fax:310-360-0759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY433613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013008630Medicaid
1993023OtherPK
1993023OtherPK