Provider Demographics
NPI:1851484299
Name:WILSHIRE WESTGATE PHARMACY
Entity Type:Organization
Organization Name:WILSHIRE WESTGATE PHARMACY
Other - Org Name:WILSHIRE WESTGATE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDFARB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-477-8527
Mailing Address - Street 1:11860 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6613
Mailing Address - Country:US
Mailing Address - Phone:310-477-8527
Mailing Address - Fax:310-473-0910
Practice Address - Street 1:11860 WILSHIRE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6613
Practice Address - Country:US
Practice Address - Phone:310-477-8527
Practice Address - Fax:310-473-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY414663336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000292OtherPK
CAPHA414660Medicaid
1192410001Medicare NSC