Provider Demographics
NPI:1932206919
Name:SKYPARK PHARMACY INC
Entity type:Organization
Organization Name:SKYPARK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:TUMASYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-378-0005
Mailing Address - Street 1:23451 MADISON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4736
Mailing Address - Country:US
Mailing Address - Phone:310-378-0005
Mailing Address - Fax:310-378-9397
Practice Address - Street 1:23451 MADISON ST STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4736
Practice Address - Country:US
Practice Address - Phone:310-378-0005
Practice Address - Fax:310-378-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46331333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA463310Medicaid
CA5254750001Medicare ID - Type Unspecified