Healthcare Provider Details

I. General information

NPI: 1285959007
Provider Name (Legal Business Name): EGYPTIAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 CALIFORNIA AVE
CORONA CA
92881-6477
US

IV. Provider business mailing address

1875 CALIFORNIA AVE
CORONA CA
92881-6477
US

V. Phone/Fax

Practice location:
  • Phone: 951-817-1005
  • Fax: 951-817-1020
Mailing address:
  • Phone: 951-817-1005
  • Fax: 951-817-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY51885
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MINA KOLTA
Title or Position: OWNER
Credential:
Phone: 626-513-5127