Provider Demographics
NPI:1407637044
Name:LA BREA RX INC
Entity Type:Organization
Organization Name:LA BREA RX INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERSHON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANBASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-705-5702
Mailing Address - Street 1:4314 W SLAUSON AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2853
Mailing Address - Country:US
Mailing Address - Phone:323-705-5702
Mailing Address - Fax:
Practice Address - Street 1:4314 W SLAUSON AVE FL 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2853
Practice Address - Country:US
Practice Address - Phone:323-705-5702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy