Healthcare Provider Details

I. General information

NPI: 1114901014
Provider Name (Legal Business Name): TURAJ TOM SHAFA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2005
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8733 BEVERLY BLVD STE 100
WEST HOLLYWOOD CA
90048-1890
US

IV. Provider business mailing address

8733 BEVERLY BLVD STE 100
WEST HOLLYWOOD CA
90048-1890
US

V. Phone/Fax

Practice location:
  • Phone: 310-657-1635
  • Fax: 310-657-5455
Mailing address:
  • Phone: 310-657-1635
  • Fax: 310-657-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY22051
License Number StateCA

VIII. Authorized Official

Name: TOM SHAFA
Title or Position: OWNER, PIC, AO
Credential: RPH
Phone: 310-657-1635