Provider Demographics
NPI:1306939731
Name:LDW PC INC
Entity type:Organization
Organization Name:LDW PC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHCST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLEZAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-274-0144
Mailing Address - Street 1:9400 BRIGHTON WAY
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4714
Mailing Address - Country:US
Mailing Address - Phone:310-274-0144
Mailing Address - Fax:310-275-5470
Practice Address - Street 1:9400 BRIGHTON WAY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4714
Practice Address - Country:US
Practice Address - Phone:310-274-0144
Practice Address - Fax:310-275-5470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY460723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992763OtherPK