Provider Demographics
NPI:1013270339
Name:PICO SQUARE PHARMACY RX INC
Entity Type:Organization
Organization Name:PICO SQUARE PHARMACY RX INC
Other - Org Name:PICO SQUARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AGHABABASHIRAZI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:213-385-0076
Mailing Address - Street 1:2334 W PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-4002
Mailing Address - Country:US
Mailing Address - Phone:213-385-0076
Mailing Address - Fax:213-385-0087
Practice Address - Street 1:2334 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-4002
Practice Address - Country:US
Practice Address - Phone:213-385-0076
Practice Address - Fax:213-385-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY50810333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY50810OtherRETAIL PHARMACY PERMIT