Provider Demographics
NPI:1144220492
Name:BDO CORPORATION
Entity Type:Organization
Organization Name:BDO CORPORATION
Other - Org Name:FAIRFAX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-565-8622
Mailing Address - Street 1:1111 N FAIRFAX AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5363
Mailing Address - Country:US
Mailing Address - Phone:323-656-9622
Mailing Address - Fax:323-656-9718
Practice Address - Street 1:1111 N FAIRFAX AVE STE 110
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5363
Practice Address - Country:US
Practice Address - Phone:323-656-9622
Practice Address - Fax:323-656-9718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
CAPHY418773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA418770Medicaid
1994763OtherPK
CAPHA418770Medicaid