Healthcare Provider Details

I. General information

NPI: 1265788558
Provider Name (Legal Business Name): PHARMACY 90210 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9735 WILSHIRE BLVD SUITE 110
BEVERLY HILLS CA
90212-2107
US

IV. Provider business mailing address

9735 WILSHIRE BLVD SUITE 110
BEVERLY HILLS CA
90212-2107
US

V. Phone/Fax

Practice location:
  • Phone: 310-777-2000
  • Fax: 310-777-2001
Mailing address:
  • Phone: 310-777-2000
  • Fax: 310-777-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number51013
License Number StateCA

VIII. Authorized Official

Name: SHAHRAM SOROUDI
Title or Position: PRESIDENT, CEO, PIC
Credential:
Phone: 310-777-2000