Provider Demographics
NPI:1831584812
Name:INSURE NUTRITION INC
Entity type:Organization
Organization Name:INSURE NUTRITION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARGOL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOSTANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-597-2555
Mailing Address - Street 1:440 HINDRY AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-2031
Mailing Address - Country:US
Mailing Address - Phone:877-513-5810
Mailing Address - Fax:877-847-9589
Practice Address - Street 1:440 HINDRY AVE
Practice Address - Street 2:SUITE F
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-2031
Practice Address - Country:US
Practice Address - Phone:877-513-5810
Practice Address - Fax:877-847-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519853336C0003X, 3336S0011X
3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51985OtherRETAIL PHARMACY LICENSE