Provider Demographics
NPI:1174693253
Name:APOTHECARY SHOP OF LOS ANGELES INC
Entity type:Organization
Organization Name:APOTHECARY SHOP OF LOS ANGELES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MUSIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:623-434-3657
Mailing Address - Street 1:1606 W WHISPERING WIND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0678
Mailing Address - Country:US
Mailing Address - Phone:623-434-3659
Mailing Address - Fax:623-434-3673
Practice Address - Street 1:325 N LARCHMONT BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3011
Practice Address - Country:US
Practice Address - Phone:323-466-1414
Practice Address - Fax:323-466-1333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APOTHECARY HOLDINGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-08
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 498363336S0011X, 3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN874AOtherMEDICARE PART B MASS IMMUNIZATION ROSTER BILLER
0519263OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA165980Medicaid
CAPHA165980Medicaid