Provider Demographics
NPI:1285959007
Name:EGYPTIAN INC
Entity type:Organization
Organization Name:EGYPTIAN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-513-5127
Mailing Address - Street 1:1875 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-6477
Mailing Address - Country:US
Mailing Address - Phone:951-817-1005
Mailing Address - Fax:951-817-1020
Practice Address - Street 1:1875 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-6477
Practice Address - Country:US
Practice Address - Phone:951-817-1005
Practice Address - Fax:951-817-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
CAPHY518853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285959007Medicaid
2124630OtherPK
2124630OtherPK