Provider Demographics
NPI:1831613793
Name:POWAY PHARMACY LLC
Entity type:Organization
Organization Name:POWAY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:GHOLAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUZITALAB
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:858-842-4206
Mailing Address - Street 1:14837 POMERADO RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2803
Mailing Address - Country:US
Mailing Address - Phone:858-842-4206
Mailing Address - Fax:858-842-4257
Practice Address - Street 1:14837 POMERADO RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2803
Practice Address - Country:US
Practice Address - Phone:858-842-4206
Practice Address - Fax:951-674-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA556233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170472OtherPK
CA1033565080OtherINDIVIDUAL NPI