Provider Demographics
NPI:1699755637
Name:PEDIATRIC CARE PHARMACY INC
Entity type:Organization
Organization Name:PEDIATRIC CARE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIAUTAUD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:213-413-2343
Mailing Address - Street 1:4616 DE LONGPRE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6076
Mailing Address - Country:US
Mailing Address - Phone:213-413-2343
Mailing Address - Fax:323-913-5820
Practice Address - Street 1:4616 DE LONGPRE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6076
Practice Address - Country:US
Practice Address - Phone:323-913-5801
Practice Address - Fax:323-913-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABP3394397333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0565905OtherNABP
CAPHA376820Medicaid
CA08980001Medicare ID - Type Unspecified