Provider Demographics
NPI:1164042453
Name:CLOVER CARE PHARMACY INC
Entity Type:Organization
Organization Name:CLOVER CARE PHARMACY INC
Other - Org Name:CLOVER CARE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANG
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-384-8763
Mailing Address - Street 1:266 S HARVARD BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4389
Mailing Address - Country:US
Mailing Address - Phone:213-384-8763
Mailing Address - Fax:213-384-7521
Practice Address - Street 1:266 S HARVARD BLVD STE 140
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4389
Practice Address - Country:US
Practice Address - Phone:213-384-8763
Practice Address - Fax:213-384-7521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-16
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57713OtherBOARD OF PHARMACY PERMIT