Healthcare Provider Details

I. General information

NPI: 1033678248
Provider Name (Legal Business Name): KOAM PHARMACY LTC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18102 PIONEER BLVD STE 102
ARTESIA CA
90701-4400
US

IV. Provider business mailing address

18102 PIONEER BLVD STE 102
ARTESIA CA
90701-4400
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0400
  • Fax:
Mailing address:
  • Phone: 562-402-4922
  • Fax: 562-402-0671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KWANG JA KIM
Title or Position: CEO
Credential:
Phone: 562-402-4922