Provider Demographics
NPI:1093252363
Name:PHANTASTIC PHARMACY INC
Entity Type:Organization
Organization Name:PHANTASTIC PHARMACY INC
Other - Org Name:PHANTASTIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEK
Authorized Official - Middle Name:
Authorized Official - Last Name:TOROSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-849-5992
Mailing Address - Street 1:4347 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3727
Mailing Address - Country:US
Mailing Address - Phone:818-849-5992
Mailing Address - Fax:818-849-5918
Practice Address - Street 1:4347 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3727
Practice Address - Country:US
Practice Address - Phone:818-849-5992
Practice Address - Fax:818-849-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CA55411333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167337OtherPK