Healthcare Provider Details

I. General information

NPI: 1194502823
Provider Name (Legal Business Name): FOUR HORSEMEN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9922 KATELLA AVE STE P
ANAHEIM CA
92804-6419
US

IV. Provider business mailing address

9922 KATELLA AVE STE P
ANAHEIM CA
92804-6419
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-3397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN STEVEN WOLK
Title or Position: CEO
Credential:
Phone: 310-738-3337