Healthcare Provider Details

I. General information

NPI: 1033744230
Provider Name (Legal Business Name): SOCAL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 GARDEN GROVE BLVD STE 102
GARDEN GROVE CA
92843-1903
US

IV. Provider business mailing address

12555 GARDEN GROVE BLVD STE 102
GARDEN GROVE CA
92843-1903
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-0593
  • Fax: 714-636-7708
Mailing address:
  • Phone: 714-636-0593
  • Fax: 714-636-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SEID AMIR FARZAN TAVAKKOLI ISFAHANI
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 256-797-2552