Provider Demographics
NPI:1700026986
Name:PRECISE COMPOUNDING PHARMACY INC
Entity Type:Organization
Organization Name:PRECISE COMPOUNDING PHARMACY INC
Other - Org Name:PRECISE COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHKAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:310-559-5555
Mailing Address - Street 1:10844-46 WASHINGTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232
Mailing Address - Country:US
Mailing Address - Phone:310-559-5555
Mailing Address - Fax:310-559-5553
Practice Address - Street 1:10844-46 WASHINGTON BLVD,
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232
Practice Address - Country:US
Practice Address - Phone:310-559-5555
Practice Address - Fax:310-559-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CA498573336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119187OtherPK