Provider Demographics
NPI:1437160637
Name:LOS ANGELES GAY AND LESBIAN COMMUNITY SERVICE CENTER
Entity Type:Organization
Organization Name:LOS ANGELES GAY AND LESBIAN COMMUNITY SERVICE CENTER
Other - Org Name:JEFFREY GOODMAN SPECIAL CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-993-7555
Mailing Address - Street 1:1625 SCHRADER BLVD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-993-7513
Mailing Address - Fax:323-308-4444
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-7513
Practice Address - Fax:323-308-4444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LOS ANGELES LGBT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY-451183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA 45118Medicaid
CA05-34099OtherNABP #
CA05-34099OtherNABP #