Healthcare Provider Details

I. General information

NPI: 1558125856
Provider Name (Legal Business Name): IMPERIAL BEACH PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 PALM AVE
SAN DIEGO CA
92154-1016
US

IV. Provider business mailing address

1530 PALM AVE
SAN DIEGO CA
92154-1016
US

V. Phone/Fax

Practice location:
  • Phone: 619-343-0095
  • Fax: 619-830-4590
Mailing address:
  • Phone: 619-343-0095
  • Fax: 619-830-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. PRASHANT AMRUTLAL KOYANI
Title or Position: MEMBER
Credential: PHARMD
Phone: 619-343-0095