Provider Demographics
NPI:1770687725
Name:CENTURY PICO PHARMACY INC
Entity Type:Organization
Organization Name:CENTURY PICO PHARMACY INC
Other - Org Name:CENTURY PICO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE/VP
Authorized Official - Prefix:
Authorized Official - First Name:BAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMOUHA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:210-657-6999
Mailing Address - Street 1:8722 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:310-657-6999
Mailing Address - Fax:310-657-7979
Practice Address - Street 1:8722 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:310-657-6999
Practice Address - Fax:310-657-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY410373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA410370Medicaid
1995335OtherPK
1038960001Medicare NSC