Healthcare Provider Details

I. General information

NPI: 1285649897
Provider Name (Legal Business Name): AMANITA RX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 LA VENTA DR STE 114
WESTLAKE VILLAGE CA
91361-3702
US

IV. Provider business mailing address

1250 LA VENTA DR STE 114
WESTLAKE VILLAGE CA
91361-3702
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-3974
  • Fax: 805-494-0103
Mailing address:
  • Phone: 805-497-3974
  • Fax: 805-494-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY55875
License Number StateCA

VIII. Authorized Official

Name: SEEMA PATEL
Title or Position: CEO
Credential:
Phone: 818-389-6381