=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104800457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASEO PHARMACY LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2005
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2237 E COLORADO BLVD B104
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-564-1000
-----------------------------------------------------
Fax | 626-583-8833
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2237 E COLORADO BLVD B104
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-564-1001
-----------------------------------------------------
Fax | 626-583-8833
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. ANDRE SAROUGHIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-564-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | PHY 51907
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHY 51907
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY 51907
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------