Provider Demographics
NPI:1821137118
Name:BOONAM SHIN
Entity Type:Organization
Organization Name:BOONAM SHIN
Other - Org Name:111 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOONAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:323-742-8111
Mailing Address - Street 1:111 W BEVERLY BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4312
Mailing Address - Country:US
Mailing Address - Phone:323-724-8111
Mailing Address - Fax:323-724-1754
Practice Address - Street 1:111 W BEVERLY BLVD
Practice Address - Street 2:STE B
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4312
Practice Address - Country:US
Practice Address - Phone:323-724-8111
Practice Address - Fax:323-724-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY410233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0523008OtherOTHER ID NUMBER
CAPHA410230Medicaid
1158670001Medicare NSC
1821137118Medicare NSC