Provider Demographics
NPI:1730244153
Name:IKENNA CORPORATION
Entity type:Organization
Organization Name:IKENNA CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NWANMA
Authorized Official - Middle Name:
Authorized Official - Last Name:IREGBULEM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:213-622-5696
Mailing Address - Street 1:312 W 5TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1900
Mailing Address - Country:US
Mailing Address - Phone:213-622-5696
Mailing Address - Fax:213-622-5932
Practice Address - Street 1:312 W 5TH ST STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1981
Practice Address - Country:US
Practice Address - Phone:213-622-5696
Practice Address - Fax:213-622-5932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY475583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064879OtherPK
CAPHY348190Medicaid