Provider Demographics
NPI:1609981638
Name:PASADENA CITY PHARMACY
Entity Type:Organization
Organization Name:PASADENA CITY PHARMACY
Other - Org Name:PASADENA CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEREDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-797-6661
Mailing Address - Street 1:1684 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2757
Mailing Address - Country:US
Mailing Address - Phone:626-797-6661
Mailing Address - Fax:626-797-9415
Practice Address - Street 1:1684 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2757
Practice Address - Country:US
Practice Address - Phone:626-797-6661
Practice Address - Fax:626-797-9415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY408263336C0003X
CAPHA408260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996085OtherPK
CAPHA408260Medicaid
0521131OtherOTHER ID NUMBER-COMMERCIAL NUMBER