MEDICARE: CALIFORNIA SPECIALTY PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PH24882	FL
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	54320	CA
4	3336S0011X	Specialty Pharmacy
5	332B00000X	Durable Medical Equipment & Medical Supplies	PMP-666	HI
6	3336H0001X	Home Infusion Therapy Pharmacy

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	7485260001	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	550007732	OTHER	CA	STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH - HOME HEALTH
5	2125569	OTHER		PK

General Provider Information

NPI Number	:	1114239332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA SPECIALTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	12110 HADLEY ST STE B
Second Line	:
City	:	WHITTIER
State	:	CA
Zip	:	90601-3912
Country	:	US
Telephone Number	:	877-802-7779
Fax Number	:	866-853-6555

Provider Business Practice Location Address
First Line	:	12110 HADLEY ST STE B
Second Line	:
City	:	WHITTIER
State	:	CA
Zip	:	90601-3912
Country	:	US
Telephone Number	:	877-802-7779
Fax Number	:	866-853-6555

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. GEORGE WORTHINGTON KRIDNER IV
Credential	:	PHARMD
Telephone Number	:	714-981-6871

Provider Enumeration Date	:	07/02/2010
Last Update Date	:	12/30/2025

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