Provider Demographics
NPI:1033744230
Name:SOCAL PHARMACY LLC
Entity Type:Organization
Organization Name:SOCAL PHARMACY LLC
Other - Org Name:GROVE HARBOR MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEID AMIR FARZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVAKKOLI ISFAHANI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:256-797-2552
Mailing Address - Street 1:12555 GARDEN GROVE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1903
Mailing Address - Country:US
Mailing Address - Phone:714-636-0593
Mailing Address - Fax:714-636-7708
Practice Address - Street 1:12555 GARDEN GROVE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1903
Practice Address - Country:US
Practice Address - Phone:714-636-0593
Practice Address - Fax:714-636-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1649713777Medicaid