Provider Demographics
NPI:1225409238
Name:PHARMEDQUEST PHARMACY SERVICES
Entity Type:Organization
Organization Name:PHARMEDQUEST PHARMACY SERVICES
Other - Org Name:AVITA PHARMACY 1008
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSING & CREDENTIALING COORDINAT
Authorized Official - Prefix:MS
Authorized Official - First Name:DALILA
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:657-286-7957
Mailing Address - Street 1:10604 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4015
Mailing Address - Country:US
Mailing Address - Phone:714-599-8181
Mailing Address - Fax:714-592-8242
Practice Address - Street 1:6801 COLDWATER CANYON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-5162
Practice Address - Country:US
Practice Address - Phone:818-301-6378
Practice Address - Fax:818-301-6340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA536213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225409238Medicaid
2154392OtherPK