Provider Demographics
NPI:1124484209
Name:GRAND VENICE LLC
Entity type:Organization
Organization Name:GRAND VENICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/RPH
Authorized Official - Prefix:DR
Authorized Official - First Name:KATAYOUN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BARKHORBAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:213-480-1300
Mailing Address - Street 1:2974 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1101
Mailing Address - Country:US
Mailing Address - Phone:213-480-1300
Mailing Address - Fax:213-480-1301
Practice Address - Street 1:2974 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1101
Practice Address - Country:US
Practice Address - Phone:213-480-1300
Practice Address - Fax:213-480-1301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY540823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY54082OtherBOARD OF PHARMACY RETAIL PERMIT
CA56-58426OtherNCPDP PROVIDER