Provider Demographics
NPI:1275669020
Name:COMPOUNDING PHARMACY ASSOCIATES AND CONSULTANTS INC
Entity Type:Organization
Organization Name:COMPOUNDING PHARMACY ASSOCIATES AND CONSULTANTS INC
Other - Org Name:PORTOLA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GENEVA
Authorized Official - Middle Name:GE
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D PHD
Authorized Official - Phone:323-222-2362
Mailing Address - Street 1:3408 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-1934
Mailing Address - Country:US
Mailing Address - Phone:323-222-2362
Mailing Address - Fax:323-225-4171
Practice Address - Street 1:3408 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-1934
Practice Address - Country:US
Practice Address - Phone:323-222-2362
Practice Address - Fax:323-225-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X, 333600000X
CAPHY552603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275669020Medicaid
CAPHY55260OtherCALIFORNIA STATE BOARD OF PHARMACY PERMIT
CA05-10760OtherNCPDP NUMBER