Provider Demographics
NPI:1124141270
Name:6122PHARMACY
Entity type:Organization
Organization Name:6122PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-725-1250
Mailing Address - Street 1:6122 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4504
Mailing Address - Country:US
Mailing Address - Phone:323-725-1250
Mailing Address - Fax:323-726-9091
Practice Address - Street 1:6122 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4504
Practice Address - Country:US
Practice Address - Phone:323-725-1250
Practice Address - Fax:323-726-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY304573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA304570Medicaid
CAPHA304570Medicaid