Provider Demographics
NPI:1417346305
Name:CRENSHAW PHARMACY INC
Entity Type:Organization
Organization Name:CRENSHAW PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ARDALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:310-402-7318
Mailing Address - Street 1:3631 CRENSHAW BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-4869
Mailing Address - Country:US
Mailing Address - Phone:323-732-5555
Mailing Address - Fax:323-734-5555
Practice Address - Street 1:3631 CRENSHAW BLVD
Practice Address - Street 2:STE 111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4869
Practice Address - Country:US
Practice Address - Phone:323-732-5555
Practice Address - Fax:323-734-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA542483336C0003X
CAPHY559903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417346305Medicaid