Healthcare Provider Details

I. General information

NPI: 1710097886
Provider Name (Legal Business Name): PRT RX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W. PICO BLVD.
LOS ANGELES CA
90035-2206
US

IV. Provider business mailing address

8700 W. PICO BLVD.
LOS ANGELES CA
90035-2206
US

V. Phone/Fax

Practice location:
  • Phone: 310-289-6590
  • Fax: 310-289-8825
Mailing address:
  • Phone: 310-289-6590
  • Fax: 310-289-8825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY 44728
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ASSDOLLAH TOOLAMI-VAGHEI
Title or Position: PRESIDENT/OWNER
Credential: R.PH.
Phone: 310-289-6590