Provider Demographics
NPI:1417231630
Name:KING'S PHARMACY AND COMPOUNDING CENTER
Entity Type:Organization
Organization Name:KING'S PHARMACY AND COMPOUNDING CENTER
Other - Org Name:KING'S PHARMACY AND COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:REZAEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-244-9415
Mailing Address - Street 1:510 SUPERIOR AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3663
Mailing Address - Country:US
Mailing Address - Phone:949-631-4624
Mailing Address - Fax:949-631-4626
Practice Address - Street 1:510 SUPERIOR AVE STE 120
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3665
Practice Address - Country:US
Practice Address - Phone:949-631-4624
Practice Address - Fax:949-631-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY507503336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132199OtherPK