Provider Demographics
NPI:1750667986
Name:FOUR SEASONS PHARMACY INC
Entity Type:Organization
Organization Name:FOUR SEASONS PHARMACY INC
Other - Org Name:FOUR SEASONS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FUNG-WAH
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-285-9698
Mailing Address - Street 1:7872 WALKER ST STE 106
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1748
Mailing Address - Country:US
Mailing Address - Phone:714-690-0349
Mailing Address - Fax:714-509-1278
Practice Address - Street 1:7872 WALKER ST STE 106
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1748
Practice Address - Country:US
Practice Address - Phone:714-690-0349
Practice Address - Fax:714-509-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336L0003X, 332B00000X, 333600000X, 3336C0003X
CAPHY506633336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750667986Medicaid
2132478OtherPK
2132478OtherPK