=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528298064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IM PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2009
-----------------------------------------------------
Last Update Date | 12/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10970 SHERMAN WAY STE 110
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-847-8600
-----------------------------------------------------
Fax | 818-847-8698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10970 SHERMAN WAY SUITE 110
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-847-8600
-----------------------------------------------------
Fax | 818-847-8698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PIC
-----------------------------------------------------
Name | MR. IGOR MARTINOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-335-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHY51128
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY51128
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------