Healthcare Provider Details

I. General information

NPI: 1053454561
Provider Name (Legal Business Name): MVP COMPOUNDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 15TH ST STE 100
SANTA MONICA CA
90404-1135
US

IV. Provider business mailing address

1260 15TH ST STE 100
SANTA MONICA CA
90404-1135
US

V. Phone/Fax

Practice location:
  • Phone: 310-393-6767
  • Fax: 310-393-6729
Mailing address:
  • Phone: 310-393-6767
  • Fax: 310-393-6729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY 51669
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHY 51669
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY 51669
License Number StateCA

VIII. Authorized Official

Name: DR. MOUIZ KOHANGHADOSH
Title or Position: PRESIDENT/PIC
Credential: PHARMD
Phone: 310-393-6767