Provider Demographics
NPI:1639180227
Name:PROVIDENCE PHARMACEUTICALS INC
Entity type:Organization
Organization Name:PROVIDENCE PHARMACEUTICALS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-353-2699
Mailing Address - Street 1:15435 S WESTERN AVE
Mailing Address - Street 2:STE 100 C
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4323
Mailing Address - Country:US
Mailing Address - Phone:310-353-2695
Mailing Address - Fax:310-353-2696
Practice Address - Street 1:15435 S WESTERN AVE
Practice Address - Street 2:STE 100 C
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4323
Practice Address - Country:US
Practice Address - Phone:310-353-2695
Practice Address - Fax:310-353-2696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY516803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143869OtherPK
2143869OtherPK