Provider Demographics
NPI:1740585835
Name:GOLDEN COVE PHARMACY AND MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:GOLDEN COVE PHARMACY AND MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-750-6082
Mailing Address - Street 1:31238 PALOS VERDES DR W
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5361
Mailing Address - Country:US
Mailing Address - Phone:310-750-6082
Mailing Address - Fax:310-750-6083
Practice Address - Street 1:31238 PALOS VERDES DR W
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-5361
Practice Address - Country:US
Practice Address - Phone:310-750-6082
Practice Address - Fax:310-750-6083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA505463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128525OtherPK
CA6676320001Medicare NSC