Basic Information
| Provider Information | |||||||||
| NPI: | 1033678248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOAM PHARMACY LTC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18102 PIONEER BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ARTESIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907013997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624023636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18102 PIONEER BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | ARTESIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907014400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624020400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | KWANG | ||||||||
| AuthorizedOfficialMiddleName: | JA | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5624024922 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1033678248 | 05 | CA | MEDICAID |