Provider Demographics
NPI:1477615003
Name:OLYMPIA PLAZA PHARMACY INC
Entity Type:Organization
Organization Name:OLYMPIA PLAZA PHARMACY INC
Other - Org Name:OLYMPIA PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOROKHOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:323-937-2590
Mailing Address - Street 1:5901 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4667
Mailing Address - Country:US
Mailing Address - Phone:323-937-2590
Mailing Address - Fax:323-937-0259
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-937-2590
Practice Address - Fax:323-937-0259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY484163336C0003X
CAPHY 484163336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0597902OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CA1477615003Medicaid
CA1477615003Medicaid