Provider Demographics
NPI:1063407252
Name:SORTPAK RX, INC.
Entity type:Organization
Organization Name:SORTPAK RX, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRVANYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-570-7787
Mailing Address - Street 1:655 N CENTRAL AVE FL 22
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1444
Mailing Address - Country:US
Mailing Address - Phone:877-570-7787
Mailing Address - Fax:877-475-2382
Practice Address - Street 1:655 N CENTRAL AVE FL 22
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1444
Practice Address - Country:US
Practice Address - Phone:877-570-7787
Practice Address - Fax:877-475-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0524733OtherNABP
CAPHY59170OtherBOARD OF PHARMACY
CAFS7677428OtherDEA LICENSE