Basic Information
| Provider Information | |||||||||
| NPI: | 1518038215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KOAM PHARMACY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KOAM PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 18102 PIONEER BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ARTESIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907013953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624023636 | ||||||||
| FaxNumber: | 5624023676 | ||||||||
| Practice Location | |||||||||
| Address1: | 18102 PIONEER BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ARTESIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907013953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624023636 | ||||||||
| FaxNumber: | 5624023676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | KWANG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5624023636 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PHY43380 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1997467 | 01 | PK | OTHER | PHY433800 | 05 | CA | MEDICAID |