Provider Demographics
NPI:1558125856
Name:IMPERIAL BEACH PHARMACY LLC
Entity Type:Organization
Organization Name:IMPERIAL BEACH PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASHANT
Authorized Official - Middle Name:AMRUTLAL
Authorized Official - Last Name:KOYANI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:619-343-0095
Mailing Address - Street 1:1530 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1016
Mailing Address - Country:US
Mailing Address - Phone:619-343-0095
Mailing Address - Fax:619-830-4590
Practice Address - Street 1:1530 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1016
Practice Address - Country:US
Practice Address - Phone:619-343-0095
Practice Address - Fax:619-830-4590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy