MEDICARE: WESTSIDE BOUTIQUE PHARMACY INC

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	3336S0011X	Specialty Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY45059	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0559522	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336150960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTSIDE BOUTIQUE PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 5063
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91221-1063
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7643 N SAN FERNANDO RD
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-1073
Country	:	US
Telephone Number	:	818-504-6444
Fax Number	:	818-504-6441

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	SEVAK OLMESSEKIAN
Credential	:
Telephone Number	:	323-533-5516

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	06/19/2009

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