MEDICARE: PLATINUM PHARMACY INC.

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	3336S0011X	Specialty Pharmacy
2	333600000X	Pharmacy
3	3336C0004X	Compounding Pharmacy
4	3336C0003X	Community/Retail Pharmacy	54308	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2131925	OTHER		PK

General Provider Information

NPI Number	:	1568744647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLATINUM PHARMACY INC.

Provider Business Mailing Address
First Line	:	1377 WESTWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4940
Country	:	US
Telephone Number	:	310-444-7979
Fax Number	:	310-444-7971

Provider Business Practice Location Address
First Line	:	1377 WESTWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4940
Country	:	US
Telephone Number	:	310-444-7979
Fax Number	:	310-444-7971

Authorized Official
Title or Position	:	OWNER/PIC
Name	:	MARYEM AKHAVANROOFIGAR
Credential	:	RPH
Telephone Number	:	310-709-3581

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	02/20/2017

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Directions to “PLATINUM PHARMACY INC. ” Practice Location

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