Provider Demographics
NPI:1952405904
Name:CRENSHAW PHARMCARE INC
Entity type:Organization
Organization Name:CRENSHAW PHARMCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HYO SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-295-5585
Mailing Address - Street 1:3756 SANTA ROSALIA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3606
Mailing Address - Country:US
Mailing Address - Phone:323-295-5585
Mailing Address - Fax:323-293-7789
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3606
Practice Address - Country:US
Practice Address - Phone:323-295-5585
Practice Address - Fax:323-293-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY447063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992762OtherPK
CAPHA447060Medicaid
0509298OtherNCPDP PROVIDER IDENTIFICATION NUMBER