Provider Demographics
NPI:1710097886
Name:PRT RX, INC.
Entity Type:Organization
Organization Name:PRT RX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ASSDOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TOOLAMI-VAGHEI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:310-289-6590
Mailing Address - Street 1:8700 W. PICO BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2206
Mailing Address - Country:US
Mailing Address - Phone:310-289-6590
Mailing Address - Fax:310-289-8825
Practice Address - Street 1:8700 W. PICO BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2206
Practice Address - Country:US
Practice Address - Phone:310-289-6590
Practice Address - Fax:310-289-8825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 447283336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA447280Medicaid
CA1710097886Medicaid