Provider Demographics
NPI:1528517547
Name:PURESOURCE ADVANCED INC
Entity type:Organization
Organization Name:PURESOURCE ADVANCED INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-639-0108
Mailing Address - Street 1:10630 SEPULVEDA BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1938
Mailing Address - Country:US
Mailing Address - Phone:818-639-0108
Mailing Address - Fax:818-639-0118
Practice Address - Street 1:10630 SEPULVEDA BLVD
Practice Address - Street 2:STE 101
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1938
Practice Address - Country:US
Practice Address - Phone:818-639-0108
Practice Address - Fax:818-639-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA556643336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy