Provider Demographics
NPI:1285713941
Name:NEWPORT CENTER PHARMACY
Entity type:Organization
Organization Name:NEWPORT CENTER PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PIC
Authorized Official - Prefix:
Authorized Official - First Name:NILOUFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHORSHID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-640-1320
Mailing Address - Street 1:1401 AVOCADO AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8700
Mailing Address - Country:US
Mailing Address - Phone:949-640-1320
Mailing Address - Fax:949-640-1324
Practice Address - Street 1:1401 AVOCADO AVE STE 104
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8700
Practice Address - Country:US
Practice Address - Phone:949-640-1320
Practice Address - Fax:949-640-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY467893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1995351OtherPK
CAPHA435370Medicaid
0518413OtherOTHER ID NUMBER-COMMERCIAL NUMBER