Healthcare Provider Details

I. General information

NPI: 1699755637
Provider Name (Legal Business Name): PEDIATRIC CARE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4616 DE LONGPRE AVE
LOS ANGELES CA
90027-6076
US

IV. Provider business mailing address

4616 DE LONGPRE AVE
LOS ANGELES CA
90027-6076
US

V. Phone/Fax

Practice location:
  • Phone: 323-913-5801
  • Fax: 323-913-5820
Mailing address:
  • Phone: 213-413-2343
  • Fax: 323-913-5820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberBP3394397
License Number StateCA

VIII. Authorized Official

Name: THOMAS J LIAUTAUD
Title or Position: PRESIDENT
Credential: RPH
Phone: 213-413-2343