=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770797847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHALOM RX INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18000 VENTURA BLVD STE 2
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-3533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-774-1800
-----------------------------------------------------
Fax | 818-774-1188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18000 VENTURA BLVD STE 2
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-3533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-774-1800
-----------------------------------------------------
Fax | 818-774-1188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | BABAK KOHANCHI
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 818-774-1800
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------