Provider Demographics
NPI:1366453854
Name:OCEAN PARK PHARMACY
Entity type:Organization
Organization Name:OCEAN PARK PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-452-5705
Mailing Address - Street 1:2731 OCEAN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5205
Mailing Address - Country:US
Mailing Address - Phone:310-452-5705
Mailing Address - Fax:310-452-2508
Practice Address - Street 1:2731 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5205
Practice Address - Country:US
Practice Address - Phone:310-452-5705
Practice Address - Fax:310-452-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY308983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA308980Medicaid
2005002OtherPK
CAPHA308980Medicaid