Provider Demographics
NPI:1336150960
Name:WESTSIDE BOUTIQUE PHARMACY INC
Entity Type:Organization
Organization Name:WESTSIDE BOUTIQUE PHARMACY INC
Other - Org Name:WESTSIDE BOUTIQUE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SEVAK
Authorized Official - Middle Name:
Authorized Official - Last Name:OLMESSEKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-533-5516
Mailing Address - Street 1:PO BOX 5063
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91221-1063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7643 N SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-1073
Practice Address - Country:US
Practice Address - Phone:818-504-6444
Practice Address - Fax:818-504-6441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
CAPHY450593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0559522OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA450590Medicaid