Provider Demographics
NPI:1013908458
Name:MID WILSHIRE PHARMACY
Entity Type:Organization
Organization Name:MID WILSHIRE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:323-653-6080
Mailing Address - Street 1:6317 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5602
Mailing Address - Country:US
Mailing Address - Phone:323-653-6080
Mailing Address - Fax:323-653-2503
Practice Address - Street 1:6317 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5602
Practice Address - Country:US
Practice Address - Phone:323-653-6080
Practice Address - Fax:323-653-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY36001333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA360010Medicaid
0599273OtherNABP