Provider Demographics
NPI:1497591341
Name:MONTANA WELLNESS RX
Entity type:Organization
Organization Name:MONTANA WELLNESS RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHEDMATIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:310-451-2828
Mailing Address - Street 1:1230 MONTANA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5986
Mailing Address - Country:US
Mailing Address - Phone:310-451-2828
Mailing Address - Fax:310-451-1118
Practice Address - Street 1:1230 MONTANA AVE STE 106
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5986
Practice Address - Country:US
Practice Address - Phone:310-451-2828
Practice Address - Fax:310-451-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy