Provider Demographics
NPI:1134231053
Name:FAIR OAKS PLAZA PHARMACY CORP
Entity type:Organization
Organization Name:FAIR OAKS PLAZA PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZAHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHNIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-799-1414
Mailing Address - Street 1:1526 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:S PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3216
Mailing Address - Country:US
Mailing Address - Phone:626-799-1414
Mailing Address - Fax:626-799-7609
Practice Address - Street 1:1526 MISSION ST
Practice Address - Street 2:
Practice Address - City:S PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3216
Practice Address - Country:US
Practice Address - Phone:626-799-1414
Practice Address - Fax:626-799-7609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY471873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA471870Medicaid
2114964OtherPK
5581760001Medicare NSC