Provider Demographics
NPI:1013082783
Name:SERRAND MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:SERRAND MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANG
Authorized Official - Middle Name:KYU
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:310-472-6308
Mailing Address - Street 1:4220 WEST 3RD ST
Mailing Address - Street 2:SUITE #100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:213-381-3855
Mailing Address - Fax:213-381-3856
Practice Address - Street 1:4220 WEST 3RD ST
Practice Address - Street 2:SUITE #100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-381-3855
Practice Address - Fax:213-381-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY21856333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA218560Medicaid
CAPHY21856OtherBOARD OF PHARMACY
CAPHY21856OtherBOARD OF PHARMACY
CAPHA218560Medicaid
CAPHY21856OtherBOARD OF PHARMACY