Provider Demographics
NPI:1518304245
Name:PLAZA PHARMACY LLC
Entity Type:Organization
Organization Name:PLAZA PHARMACY LLC
Other - Org Name:PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-498-6675
Mailing Address - Street 1:2333 BORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3206
Mailing Address - Country:US
Mailing Address - Phone:805-498-6675
Mailing Address - Fax:805-498-8017
Practice Address - Street 1:430 E AVENIDA DE LOS ARBOLES
Practice Address - Street 2:SUITE 103
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3003
Practice Address - Country:US
Practice Address - Phone:805-492-2451
Practice Address - Fax:805-492-7837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY-514933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140876OtherPK