Healthcare Provider Details

I. General information

NPI: 1720650294
Provider Name (Legal Business Name): PRIME WHOLESALE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 MACHLIN CT UNIT 113
WALNUT CA
91789-3048
US

IV. Provider business mailing address

218 MACHLIN CT UNIT 113
WALNUT CA
91789-3048
US

V. Phone/Fax

Practice location:
  • Phone: 310-418-1881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. MOHAMED SHERIF
Title or Position: MANAGING PARTNER
Credential:
Phone: 310-418-1881