Provider Demographics
NPI:1023142734
Name:CENTRAL AVE PHARMACY INC
Entity type:Organization
Organization Name:CENTRAL AVE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HRACH
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSEFIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-242-8838
Mailing Address - Street 1:119 WEST CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-242-8838
Mailing Address - Fax:818-242-8837
Practice Address - Street 1:119 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2211
Practice Address - Country:US
Practice Address - Phone:818-242-8838
Practice Address - Fax:818-242-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY393633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067006OtherPK
CAPHA393630Medicaid
2067006OtherPK