Provider Demographics
NPI:1831241033
Name:IV LEAGUE, INC
Entity type:Organization
Organization Name:IV LEAGUE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARZIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALKHALI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-645-1500
Mailing Address - Street 1:PO BOX 341890
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-8802
Mailing Address - Country:US
Mailing Address - Phone:310-645-1500
Mailing Address - Fax:310-645-6464
Practice Address - Street 1:6076 BRISTOL PARKWAY
Practice Address - Street 2:#104
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-8802
Practice Address - Country:US
Practice Address - Phone:310-645-1500
Practice Address - Fax:310-645-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45770332B00000X, 332BP3500X, 3336S0011X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY45770OtherPHARMACY LICENSE
CAPHA457700Medicaid
CA4364730001Medicare ID - Type UnspecifiedMEDICARE