Provider Demographics
NPI:1336260348
Name:KDJ HEALTHCARE INC
Entity Type:Organization
Organization Name:KDJ HEALTHCARE INC
Other - Org Name:986 PHARMACY #8010
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-816-0270
Mailing Address - Street 1:2781-2783 W. OLYMPIC BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2632
Mailing Address - Country:US
Mailing Address - Phone:213-816-0270
Mailing Address - Fax:213-816-0271
Practice Address - Street 1:2781-2783 W. OLYMPIC BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2632
Practice Address - Country:US
Practice Address - Phone:213-816-0270
Practice Address - Fax:213-816-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 333600000X, 3336C0003X
CAPHY490943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA58812OtherCA BOARD OF PHARMACY