Provider Demographics
NPI:1619047826
Name:ATAZAK INC
Entity Type:Organization
Organization Name:ATAZAK INC
Other - Org Name:KOVACS-FREY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ATALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-951-4456
Mailing Address - Street 1:2860 ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3421
Mailing Address - Country:US
Mailing Address - Phone:310-371-7541
Mailing Address - Fax:310-542-1488
Practice Address - Street 1:2860 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3421
Practice Address - Country:US
Practice Address - Phone:310-371-7541
Practice Address - Fax:310-542-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY533713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154379OtherPK
CA6048190001Medicare NSC
CAPHA417160OtherMEDICAL TAR NUMBER
CA0512310Medicare UPIN
CA954581814OtherTAX PAYER ID NUMBER
CABM5136874OtherDEA NUMBER