Healthcare Provider Details

I. General information

NPI: 1679308977
Provider Name (Legal Business Name): PERIGON PHARMACY 360 NW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 N MOORPARK RD
THOUSAND OAKS CA
91360-3702
US

IV. Provider business mailing address

442 N MOORPARK RD
THOUSAND OAKS CA
91360-3702
US

V. Phone/Fax

Practice location:
  • Phone: 805-874-2025
  • Fax:
Mailing address:
  • Phone: 805-874-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER ANTYPAS
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 805-874-2025