Provider Demographics
NPI:1669569810
Name:P.S. ENTERPRISE, INC
Entity type:Organization
Organization Name:P.S. ENTERPRISE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHIC KAING
Authorized Official - Middle Name:
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM D
Authorized Official - Phone:626-287-9921
Mailing Address - Street 1:2300 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2641
Mailing Address - Country:US
Mailing Address - Phone:626-287-9921
Mailing Address - Fax:626-285-0644
Practice Address - Street 1:2300 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2641
Practice Address - Country:US
Practice Address - Phone:626-287-9921
Practice Address - Fax:626-285-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X, 333600000X
CAPHY452383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0524846OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA452380Medicaid
CA5399520001Medicare NSC