=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003281593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAC RX, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2015
-----------------------------------------------------
Last Update Date | 06/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18075 VENTURA BLVD SUITE #112
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-975-8612
-----------------------------------------------------
Fax | 818-975-8613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18075 VENTURA BLVD SUITE #112
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-975-8612
-----------------------------------------------------
Fax | 818-975-8613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PIC
-----------------------------------------------------
Name | MEHRNAZ SALEHPOUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-975-8612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 53851
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------