Provider Demographics
NPI:1124157904
Name:KNOLLS PHARMACY
Entity type:Organization
Organization Name:KNOLLS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-454-6000
Mailing Address - Street 1:16630 MARQUEZ AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3233
Mailing Address - Country:US
Mailing Address - Phone:310-454-6000
Mailing Address - Fax:310-454-0605
Practice Address - Street 1:16630 MARQUEZ AVE
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3233
Practice Address - Country:US
Practice Address - Phone:310-454-6000
Practice Address - Fax:310-454-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY369243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1994466OtherPK