=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730274903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMISOLA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 10/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11011 CRENSHAW BLVD STE 102
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90303-6330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-677-6522
-----------------------------------------------------
Fax | 310-677-6562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11011 CRENSHAW BLVD STE 102
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90303-6330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-677-6522
-----------------------------------------------------
Fax | 310-677-6562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ CEO
-----------------------------------------------------
Name | MR. MARKSON B ALABI
-----------------------------------------------------
Credential | CO
-----------------------------------------------------
Telephone | 310-677-6522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PHA443050
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | PHA443050
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY44305
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------