Healthcare Provider Details

I. General information

NPI: 1609729961
Provider Name (Legal Business Name): FAIRY BUNDLES BAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 E COLORADO BLVD # 5
PASADENA CA
91106-2327
US

IV. Provider business mailing address

1055 E COLORADO BLVD # 1300
PASADENA CA
91106-2327
US

V. Phone/Fax

Practice location:
  • Phone: 626-831-5410
  • Fax:
Mailing address:
  • Phone: 626-831-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DEDRA AKINS
Title or Position: OWNER
Credential:
Phone: 626-831-5410