1631 Montana Ave Pharmacy, LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PHY 49018 Issued in CA

Legal business name

1631 MONTANA AVE PHARMACY, LLC

Practice address

1631 Montana Ave
Santa Monica, CA 90403-1807

Phone

(310) 393-0761

Fax

(310) 395-6654

NPI assigned

Aug 1, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Eleanor Kong, PHARMD

Title

Pharmacist in Charge

Phone

(310) 393-0761

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• REGENT SQUARE PHARMACY Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Shirin Ghafouri, PHARMD

  • Pharmacist
  • Santa Monica, CA
  • NPI 1396881298
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154390400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1208131200000",
    "number": "1881600476",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1631 MONTANA AVE",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904031807",
            "telephone_number": "310-393-0761",
            "fax_number": "310-395-6654"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1631 MONTANA AVE",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904031807",
            "telephone_number": "310-393-0761",
            "fax_number": "310-395-6654"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1631 MONTANA AVE PHARMACY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-01",
        "last_updated": "2008-04-14",
        "status": "A",
        "authorized_official_last_name": "KONG",
        "authorized_official_first_name": "ELEANOR",
        "authorized_official_title_or_position": "PHARMACIST IN CHARGE",
        "authorized_official_telephone_number": "310-393-0761",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CA",
            "license": "PHY 49018",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "PHA465390",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "05-73065",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "REGENT SQUARE PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Retail Pharmacy in Santa Monica, CA
• Providers in Santa Monica, CA by specialty
• Community/Retail Pharmacy in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.