Provider Demographics
NPI:1083768352
Name:WILBUR FAMILY PHARMACY
Entity Type:Organization
Organization Name:WILBUR FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:P
Authorized Official - Last Name:SEIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:818-342-6520
Mailing Address - Street 1:5620 WILBUR AVE
Mailing Address - Street 2:100
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1351
Mailing Address - Country:US
Mailing Address - Phone:818-342-6520
Mailing Address - Fax:818-342-6523
Practice Address - Street 1:5620 WILBUR AVE
Practice Address - Street 2:100
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1351
Practice Address - Country:US
Practice Address - Phone:818-342-6520
Practice Address - Fax:818-342-6523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29380333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY226840Medicaid