Provider Demographics
NPI:1972270932
Name:BLAST PHARMA INC
Entity Type:Organization
Organization Name:BLAST PHARMA INC
Other - Org Name:BLAST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-733-7978
Mailing Address - Street 1:1807 W KATELLA AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6691
Mailing Address - Country:US
Mailing Address - Phone:714-733-7879
Mailing Address - Fax:714-733-7969
Practice Address - Street 1:1807 W KATELLA AVE STE 206
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6691
Practice Address - Country:US
Practice Address - Phone:714-733-7879
Practice Address - Fax:714-733-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy