=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770687725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTURY PICO PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 05/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8722 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-657-6999
-----------------------------------------------------
Fax | 310-657-7979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8722 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-657-6999
-----------------------------------------------------
Fax | 310-657-7979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE/VP
-----------------------------------------------------
Name | BAHRAM SAMOUHA
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 210-657-6999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY41037
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------