Provider Demographics
NPI:1548275324
Name:KOMOTO PHARMACY, INC.
Entity type:Organization
Organization Name:KOMOTO PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:661-725-9489
Mailing Address - Street 1:1017 ELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2621
Mailing Address - Country:US
Mailing Address - Phone:661-725-9489
Mailing Address - Fax:661-721-2537
Practice Address - Street 1:1017 ELLINGTON ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2621
Practice Address - Country:US
Practice Address - Phone:661-725-9489
Practice Address - Fax:661-721-2537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 34707183500000X
CAPHY34707332BP3500X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral NutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA347070OtherMEDI-CAL
CA0669950001Medicare ID - Type Unspecified