Provider Demographics
NPI:1033678248
Name:KOAM PHARMACY LTC INC
Entity Type:Organization
Organization Name:KOAM PHARMACY LTC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KWANG
Authorized Official - Middle Name:JA
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-402-4922
Mailing Address - Street 1:18102 PIONEER BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-4400
Mailing Address - Country:US
Mailing Address - Phone:562-402-4922
Mailing Address - Fax:562-402-0671
Practice Address - Street 1:18102 PIONEER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-4400
Practice Address - Country:US
Practice Address - Phone:562-402-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1033678248Medicaid