Provider Demographics
NPI:1902925571
Name:MIYADE MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:MIYADE MEDICAL CENTER PHARMACY
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AKIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYADE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:310-338-8885
Mailing Address - Street 1:6801 PARK TER
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6801 PARK TER
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-338-8885
Practice Address - Fax:310-338-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY437363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0502117OtherOTHER ID NUMBER
CAPHA437360Medicaid
0502117OtherOTHER ID NUMBER-COMMERCIAL NUMBER