Provider Demographics
NPI:1619965951
Name:GLENDALE WEST DRUG CO INC
Entity Type:Organization
Organization Name:GLENDALE WEST DRUG CO INC
Other - Org Name:GLENDALE WEST PHARMACY AND MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MALEK
Authorized Official - Middle Name:SET
Authorized Official - Last Name:ALLAHDADAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-548-5157
Mailing Address - Street 1:1109 S GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-5657
Mailing Address - Country:US
Mailing Address - Phone:818-548-5157
Mailing Address - Fax:818-548-1064
Practice Address - Street 1:1109 S GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-5657
Practice Address - Country:US
Practice Address - Phone:818-548-5157
Practice Address - Fax:818-548-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43706333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA437060Medicaid
CA1246030001Medicare ID - Type Unspecified