Provider Demographics
NPI:1629224381
Name:ABC PHARMACY INC
Entity Type:Organization
Organization Name:ABC PHARMACY INC
Other - Org Name:ABC COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ARKAIDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMIOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-363-7250
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-783-0422
Mailing Address - Fax:818-783-0423
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:STE 110
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-783-0422
Practice Address - Fax:818-783-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY491833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629224381Medicaid
2117000OtherPK