Healthcare Provider Details

I. General information

NPI: 1386738789
Provider Name (Legal Business Name): POULTER ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 PUENTE AVE
BALDWIN PARK CA
91706-5952
US

IV. Provider business mailing address

1624 PUENTE AVE
BALDWIN PARK CA
91706-5952
US

V. Phone/Fax

Practice location:
  • Phone: 626-960-4774
  • Fax: 626-960-4775
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY22183
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000