Provider Demographics
NPI:1720017874
Name:IMANOEL PHARMACY INC
Entity Type:Organization
Organization Name:IMANOEL PHARMACY INC
Other - Org Name:SUNSHINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IMANOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-653-8692
Mailing Address - Street 1:357 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2108
Mailing Address - Country:US
Mailing Address - Phone:323-653-8692
Mailing Address - Fax:323-653-3358
Practice Address - Street 1:357 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2108
Practice Address - Country:US
Practice Address - Phone:323-653-8692
Practice Address - Fax:323-653-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
CAPHY443173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY44317Medicaid
2043521OtherPK
0948320001Medicare NSC