Provider Demographics
NPI:1669642468
Name:MAGNOLIA PHARMACEUTICAL CORP
Entity Type:Organization
Organization Name:MAGNOLIA PHARMACEUTICAL CORP
Other - Org Name:MAGNOLIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PIC
Authorized Official - Prefix:
Authorized Official - First Name:KAMBIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AHADIMOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-238-0100
Mailing Address - Street 1:2211 W MAGNOLIA BLVD
Mailing Address - Street 2:115
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1753
Mailing Address - Country:US
Mailing Address - Phone:818-238-0100
Mailing Address - Fax:818-238-0115
Practice Address - Street 1:2211 W MAGNOLIA BLVD
Practice Address - Street 2:115
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1753
Practice Address - Country:US
Practice Address - Phone:818-238-0100
Practice Address - Fax:818-238-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113302OtherPK
CA6121400001Medicare NSC