Healthcare Provider Details

I. General information

NPI: 1528254885
Provider Name (Legal Business Name): GOLDEN STATE PHARMACEUTICALS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 CALLE PLANO
CAMARILLO CA
93012
US

IV. Provider business mailing address

768 CALLE PLANO
CAMARILLO CA
93012
US

V. Phone/Fax

Practice location:
  • Phone: 818-857-9217
  • Fax:
Mailing address:
  • Phone: 818-857-9217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number48647
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number48647
License Number StateCA

VIII. Authorized Official

Name: KENNETH JACK AMODEO
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 818-857-9217