Healthcare Provider Details

I. General information

NPI: 1376084202
Provider Name (Legal Business Name): GOLDEN STATE SPECIALTY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2017
Last Update Date: 03/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N VICTORY BLVD
BURBANK CA
91502-1841
US

IV. Provider business mailing address

325 N VICTORY BLVD
BURBANK CA
91502-1841
US

V. Phone/Fax

Practice location:
  • Phone: 888-658-0801
  • Fax:
Mailing address:
  • Phone: 888-658-0801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY54580
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY54580
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHY54580
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberPHY54580
License Number StateCA

VIII. Authorized Official

Name: ARMEN APOYAN
Title or Position: CFO
Credential:
Phone: 888-658-0801