Provider Demographics
NPI:1144203167
Name:PHARMACY OF THE STARS INC
Entity Type:Organization
Organization Name:PHARMACY OF THE STARS INC
Other - Org Name:PHARMACY OF THE STARS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:HYUN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:310-556-4682
Mailing Address - Street 1:1900 AVENUE OF THE STARS
Mailing Address - Street 2:SUITE A105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-4301
Mailing Address - Country:US
Mailing Address - Phone:310-556-4682
Mailing Address - Fax:310-556-4683
Practice Address - Street 1:1900 AVENUE OF THE STARS
Practice Address - Street 2:SUITE A105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-4301
Practice Address - Country:US
Practice Address - Phone:310-556-4682
Practice Address - Fax:310-556-4683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46038333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA460380Medicaid
CAPHA460380Medicaid