Provider Demographics
NPI:1215479027
Name:GARDENA PHARMACY CORPORATION
Entity type:Organization
Organization Name:GARDENA PHARMACY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:LINH
Authorized Official - Middle Name:M
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:424-329-3904
Mailing Address - Street 1:15418 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4524
Mailing Address - Country:US
Mailing Address - Phone:424-329-3904
Mailing Address - Fax:424-329-3905
Practice Address - Street 1:15418 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4524
Practice Address - Country:US
Practice Address - Phone:424-329-3904
Practice Address - Fax:424-329-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 552903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1664899027Medicaid
CAPHY 55290OtherCALIFORNIA STATE BOARD OF PHARMACY PERMIT