Basic Information
| Provider Information | |||||||||
| NPI: | 1598723579 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICINE MADE EASY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WHITTIER GOODRICH PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5417 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900224101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5417 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900224101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237221010 | ||||||||
| FaxNumber: | 3237228040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | FICHERA | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5082971018 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PHY 50169 | CA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336S0011X | PHY 50169 | CA | Y | Suppliers | Pharmacy | Specialty Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PHA 50169 | 05 | CA | MEDICAID | PHY 50169 | 01 | CA | STATE PHARMACY LIC | OTHER | 0508082 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | FW2036348 | 01 | DEA | OTHER |