Provider Demographics
NPI:1427069053
Name:EXCLUSIVE PRESCRIPTION AND WELLNESS PHCY
Entity type:Organization
Organization Name:EXCLUSIVE PRESCRIPTION AND WELLNESS PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:626-644-3103
Mailing Address - Street 1:65 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2035
Practice Address - Country:US
Practice Address - Phone:626-793-3536
Practice Address - Fax:626-793-3360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY44807333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA448070Medicaid
0554990OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA448070Medicaid