Healthcare Provider Details

I. General information

NPI: 1295083764
Provider Name (Legal Business Name): GRACE RX PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 E WASHINGTON BLVD
PASADENA CA
91104-2751
US

IV. Provider business mailing address

1724 E WASHINGTON BLVD
PASADENA CA
91104-2751
US

V. Phone/Fax

Practice location:
  • Phone: 818-957-5555
  • Fax: 818-957-5551
Mailing address:
  • Phone: 818-957-5555
  • Fax: 818-957-5551

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 Number
License Number State

VIII. Authorized Official

Name: MADLEN BASILYAN
Title or Position: PRESIDENT/CEO
Credential: PHARM D
Phone: 818-957-5555