Provider Demographics
NPI:1891107066
Name:PHARMEDQUEST PHARMACY SERVICES
Entity Type:Organization
Organization Name:PHARMEDQUEST PHARMACY SERVICES
Other - Org Name:AVITA PHARMACY 1001
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSING & CREDENTIALING COORDINAT
Authorized Official - Prefix:MS
Authorized Official - First Name:DALILA
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:657-286-7957
Mailing Address - Street 1:10604 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4015
Mailing Address - Country:US
Mailing Address - Phone:657-286-7957
Mailing Address - Fax:714-599-8242
Practice Address - Street 1:522 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-2102
Practice Address - Country:US
Practice Address - Phone:213-443-8627
Practice Address - Fax:213-627-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51788333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891107066Medicaid