Provider Demographics
NPI:1922283621
Name:ST KEROLLOS PHARMACY INC
Entity Type:Organization
Organization Name:ST KEROLLOS PHARMACY INC
Other - Org Name:AMERICAN HOME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:HENEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-562-1577
Mailing Address - Street 1:4566 FLORENCE AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-4345
Mailing Address - Country:US
Mailing Address - Phone:323-562-1578
Mailing Address - Fax:323-562-1651
Practice Address - Street 1:4566 FLORENCE AVE
Practice Address - Street 2:STE 4
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-4345
Practice Address - Country:US
Practice Address - Phone:323-562-1578
Practice Address - Fax:323-562-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BN1400X, 333600000X, 3336C0003X, 3336M0003X, 3336S0011X
CAPHY546063336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166189OtherPK