Provider Demographics
NPI:1992882286
Name:GOODFELLOW PHARMACY
Entity type:Organization
Organization Name:GOODFELLOW PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA
Authorized Official - Prefix:MR
Authorized Official - First Name:MKRTICH
Authorized Official - Middle Name:
Authorized Official - Last Name:DISHIGRIKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-754-0949
Mailing Address - Street 1:12157 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3204
Mailing Address - Country:US
Mailing Address - Phone:818-754-0949
Mailing Address - Fax:818-754-0944
Practice Address - Street 1:12157 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3204
Practice Address - Country:US
Practice Address - Phone:818-754-0949
Practice Address - Fax:818-754-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA410310Medicaid
CA1058800001Medicare ID - Type UnspecifiedPROVIDER NUMBER