Provider Demographics
NPI:1912062332
Name:MAGIC POTION INC
Entity Type:Organization
Organization Name:MAGIC POTION INC
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GENNADY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:949-830-8500
Mailing Address - Street 1:24602 RAYMOND WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4461
Mailing Address - Country:US
Mailing Address - Phone:949-830-8500
Mailing Address - Fax:949-830-9884
Practice Address - Street 1:24602 RAYMOND WAY
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4461
Practice Address - Country:US
Practice Address - Phone:949-830-8500
Practice Address - Fax:949-830-9884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY472053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA472050Medicaid
CA0528034OtherNABP
CABT9481641OtherDEA #
CA5524880001Medicare NSC
CAPHA472050Medicaid