Provider Demographics
NPI:1659552636
Name:CHILDREN'S HOSPITAL LOS ANGELES
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL LOS ANGELES
Other - Org Name:CHILDRENS HOSPITAL LOS ANGELES SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LIEBERENZ
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:323-361-2235
Mailing Address - Street 1:4650 W SUNSET BLVD RM 1401
Mailing Address - Street 2:MAILBOX NUMBER 44
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD RM 1503
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-8839
Practice Address - Fax:323-361-7135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X, 3336S0011X
CAHSP137263336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659552636Medicaid
2062400OtherPK