Provider Demographics
NPI:1417322736
Name:SUPREME CARE PHARMACY, INC.
Entity Type:Organization
Organization Name:SUPREME CARE PHARMACY, INC.
Other - Org Name:SUPREME CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEVORG
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGORYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-763-7007
Mailing Address - Street 1:6007 LANKERSHIM BLVD
Mailing Address - Street 2:#7
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4883
Mailing Address - Country:US
Mailing Address - Phone:818-763-7007
Mailing Address - Fax:818-763-7006
Practice Address - Street 1:6007 LANKERSHIM BLVD
Practice Address - Street 2:#7
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4883
Practice Address - Country:US
Practice Address - Phone:818-763-7007
Practice Address - Fax:818-763-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 538783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY53878OtherCALLFORNIA STATE BOARD OF PHARMACY
CA56-58096OtherNCPDP PROVIDER