Provider Demographics
NPI:1285649814
Name:FRED P STARTZ
Entity Type:Organization
Organization Name:FRED P STARTZ
Other - Org Name:MARVINS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:STARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-278-7734
Mailing Address - Street 1:8933 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4912
Mailing Address - Country:US
Mailing Address - Phone:310-278-7734
Mailing Address - Fax:310-278-7748
Practice Address - Street 1:8933 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4912
Practice Address - Country:US
Practice Address - Phone:310-278-7734
Practice Address - Fax:310-278-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY433363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0598358OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA43336Medicaid