Organization
POULTER ENTERPRISES INC
Active
Other names
Medicine Shoppe
Organization subpart
No
Provider details
NPI number
Authorized official
DENA FERMAN (THIRD PARTY PLAN COORDINATOR)
(314) 993-6000
Entity
Organization
Contact information
Practice address
1624 PUENTE AVE, BALDWIN PARK, CA 91706-5952
(626) 960-4774
(626) 960-4775
Mailing address
1624 PUENTE AVE, BALDWIN PARK, CA 91706-5952
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
PHY22183
CA
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0566577
OTHER ID NUMBER-COMMERCIAL NUMBER
—
05
—
PHA 221830
—
CA
Enumeration date
10/03/2006
Last updated
03/07/2023
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