=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609327691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDRA PHARMACY LOS ANGELES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2016
-----------------------------------------------------
Last Update Date | 10/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1417 W BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-206-4466
-----------------------------------------------------
Fax | 323-477-1272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 724 ELTON AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10455-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-836-8886
-----------------------------------------------------
Fax | 323-477-1272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MAZEN KARNABY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-836-8886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 54302
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------