Provider Demographics
NPI:1134119423
Name:MARINA PHARMACY INC.
Entity Type:Organization
Organization Name:MARINA PHARMACY INC.
Other - Org Name:DBA HILLSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-376-9456
Mailing Address - Street 1:1145 ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6900
Mailing Address - Country:US
Mailing Address - Phone:310-376-9456
Mailing Address - Fax:310-376-6026
Practice Address - Street 1:1145 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6900
Practice Address - Country:US
Practice Address - Phone:310-376-9456
Practice Address - Fax:310-376-6026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45093333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA450930Medicaid
CA1276960001Medicare NSC
CA1276960001Medicare ID - Type Unspecified