Provider Demographics
NPI:1639103807
Name:MEDPRO PHARMACY INC
Entity Type:Organization
Organization Name:MEDPRO PHARMACY INC
Other - Org Name:MEDPRO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SIAVASH
Authorized Official - Middle Name:
Authorized Official - Last Name:AHDOOT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:323-939-8300
Mailing Address - Street 1:7129 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4411
Mailing Address - Country:US
Mailing Address - Phone:323-969-8300
Mailing Address - Fax:323-969-8400
Practice Address - Street 1:7129 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-4411
Practice Address - Country:US
Practice Address - Phone:323-969-8300
Practice Address - Fax:323-969-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY50438333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5622560OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHY 50438OtherSTATE BOARD OF PHARMACY RETAIL PERMIT
CA1639103807Medicaid
CA1639103807Medicaid