Provider Demographics
NPI:1114901014
Name:TURAJ TOM SHAFA
Entity Type:Organization
Organization Name:TURAJ TOM SHAFA
Other - Org Name:MID WEST MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:310-657-1635
Mailing Address - Street 1:8733 BEVERLY BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1890
Mailing Address - Country:US
Mailing Address - Phone:310-657-1635
Mailing Address - Fax:310-657-5455
Practice Address - Street 1:8733 BEVERLY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1890
Practice Address - Country:US
Practice Address - Phone:310-657-1635
Practice Address - Fax:310-657-5455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-04
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY220513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2002290OtherPK
CAPHA220510Medicaid
0706050001Medicare NSC