Provider Demographics
NPI:1811035801
Name:KT PLAZA PHARMACY, INC.
Entity Type:Organization
Organization Name:KT PLAZA PHARMACY, INC.
Other - Org Name:KT PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARAMCIST/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-382-0212
Mailing Address - Street 1:928 S WESTERN AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-1000
Mailing Address - Country:US
Mailing Address - Phone:213-382-0212
Mailing Address - Fax:213-382-0812
Practice Address - Street 1:928 S WESTERN AVE
Practice Address - Street 2:STE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-1000
Practice Address - Country:US
Practice Address - Phone:213-382-0212
Practice Address - Fax:213-382-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA544693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162516OtherPK
CA1811035801Medicaid
CAPHA436630Medicaid