Provider Demographics
NPI:1316059231
Name:PRIMECARE PHARMACY INC
Entity type:Organization
Organization Name:PRIMECARE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-382-9718
Mailing Address - Street 1:801 S. VERMONT AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-1567
Mailing Address - Country:US
Mailing Address - Phone:213-382-9718
Mailing Address - Fax:213-380-6792
Practice Address - Street 1:801 S. VERMONT AVE
Practice Address - Street 2:STE 104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1567
Practice Address - Country:US
Practice Address - Phone:213-382-9718
Practice Address - Fax:213-380-6792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY443913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA443910Medicaid
1997466OtherPK
1997466OtherPK