Healthcare Provider Details

I. General information

NPI: 1285363556
Provider Name (Legal Business Name): ANAHEIM PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W LA PALMA AVE STE 102
ANAHEIM CA
92801-2809
US

IV. Provider business mailing address

1211 W LA PALMA AVE STE 102
ANAHEIM CA
92801-2809
US

V. Phone/Fax

Practice location:
  • Phone: 714-442-1141
  • Fax: 714-442-1142
Mailing address:
  • Phone: 714-442-1141
  • Fax: 714-442-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAY KIM
Title or Position: MANAGING MEMBER
Credential:
Phone: 909-464-0300