Provider Demographics
NPI:1235130832
Name:FOX HILLS PHARMACY INC
Entity Type:Organization
Organization Name:FOX HILLS PHARMACY INC
Other - Org Name:GRAND AVENUE PHARMACIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGO
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBOL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:310-649-3775
Mailing Address - Street 1:4455 W 117TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2241
Mailing Address - Country:US
Mailing Address - Phone:310-649-3774
Mailing Address - Fax:310-649-3720
Practice Address - Street 1:4455 W 117TH ST
Practice Address - Street 2:STE 101
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2241
Practice Address - Country:US
Practice Address - Phone:310-649-3774
Practice Address - Fax:310-649-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336H0001X, 3336M0003X, 3336S0011X
CAPHY467483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2001007OtherPK
CAPHA467480Medicaid
2001007OtherPK