Provider Demographics
NPI:1801047964
Name:GRACE COMMUNITY PHARMACY, INC.
Entity type:Organization
Organization Name:GRACE COMMUNITY PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MINJUNG
Authorized Official - Middle Name:K
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, PHD
Authorized Official - Phone:562-860-0586
Mailing Address - Street 1:4881 LA PALMA AVE.
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623
Mailing Address - Country:US
Mailing Address - Phone:562-860-0586
Mailing Address - Fax:562-860-0767
Practice Address - Street 1:4881 LA PALMA AVE.
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623
Practice Address - Country:US
Practice Address - Phone:562-860-0586
Practice Address - Fax:562-860-0767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801047964Medicaid
CA1801047964Medicaid
6165580001Medicare NSC