Provider Demographics
NPI:1033586953
Name:CASA BLANCA PHARMACY INC
Entity Type:Organization
Organization Name:CASA BLANCA PHARMACY INC
Other - Org Name:CASA BLANCA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVORKYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-698-4390
Mailing Address - Street 1:2012 GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-1625
Mailing Address - Country:US
Mailing Address - Phone:818-698-4390
Mailing Address - Fax:818-698-4387
Practice Address - Street 1:2012 GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-1625
Practice Address - Country:US
Practice Address - Phone:818-698-4390
Practice Address - Fax:818-698-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA545753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153949OtherPK