Provider Demographics
NPI:1700998796
Name:PHNOM PICH PHARMACY INC
Entity Type:Organization
Organization Name:PHNOM PICH PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HENG HONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-438-3324
Mailing Address - Street 1:2338 E ANAHEIM ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-5735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2338 E ANAHEIM ST STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-5735
Practice Address - Country:US
Practice Address - Phone:562-438-3324
Practice Address - Fax:562-987-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY37082333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0507953OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA370820Medicaid
CAPHA370820Medicaid