Provider Demographics
NPI:1649267626
Name:MEDALLION PRESCRIPTION PHARMACY
Entity type:Organization
Organization Name:MEDALLION PRESCRIPTION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BEATRISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TSEYTLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:818-340-0212
Mailing Address - Street 1:23101 SHERMAN PL
Mailing Address - Street 2:SUITE #101
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2008
Mailing Address - Country:US
Mailing Address - Phone:818-789-6836
Mailing Address - Fax:818-340-5075
Practice Address - Street 1:23101 SHERMAN PL
Practice Address - Street 2:SUITE #101
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-2008
Practice Address - Country:US
Practice Address - Phone:818-789-6836
Practice Address - Fax:818-340-5075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY394090333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA394090Medicaid
CA0780720001Medicare ID - Type Unspecified