Healthcare Provider Details

I. General information

NPI: 1528298064
Provider Name (Legal Business Name): IM PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10970 SHERMAN WAY STE 110
BURBANK CA
91505-1003
US

IV. Provider business mailing address

10970 SHERMAN WAY SUITE 110
BURBANK CA
91505-1002
US

V. Phone/Fax

Practice location:
  • Phone: 818-847-8600
  • Fax: 818-847-8698
Mailing address:
  • Phone: 818-847-8600
  • Fax: 818-847-8698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY51128
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY51128
License Number StateCA

VIII. Authorized Official

Name: MR. IGOR MARTINOV
Title or Position: PRESIDENT/PIC
Credential:
Phone: 818-335-4000