MEDICARE: IMPERIAL BEACH PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1326652371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL BEACH PHARMACY LLC

Provider Business Mailing Address
First Line	:	1530 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1016
Country	:	US
Telephone Number	:	619-343-0095
Fax Number	:	619-830-4590

Provider Business Practice Location Address
First Line	:	1530 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1016
Country	:	US
Telephone Number	:	619-343-0095
Fax Number	:	619-830-4590

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. PRASHANT AMRUTLAL KOYANI
Credential	:	PHARMD
Telephone Number	:	619-343-0095

Provider Enumeration Date	:	09/06/2020
Last Update Date	:	02/08/2024

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