Provider Demographics
NPI:1730274903
Name:SIMISOLA PHARMACY INC
Entity type:Organization
Organization Name:SIMISOLA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARKSON
Authorized Official - Middle Name:B
Authorized Official - Last Name:ALABI
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:310-677-6522
Mailing Address - Street 1:11011 CRENSHAW BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-6330
Mailing Address - Country:US
Mailing Address - Phone:310-677-6522
Mailing Address - Fax:310-677-6562
Practice Address - Street 1:11011 CRENSHAW BLVD
Practice Address - Street 2:STE 102
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-6330
Practice Address - Country:US
Practice Address - Phone:310-677-6522
Practice Address - Fax:310-677-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA443050332B00000X, 335E00000X
333600000X
CAPHY443053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0513259OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA443050Medicaid
CA5622310001Medicare NSC