Organization
INFORTEL MEDICAL GROUP
Active
Other names
STATION PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ELEANOR FAM MAI KONG PHARM D (PRESIDENT/PIC)
(310) 892-0468
Entity
Organization
Contact information
Practice address
1820 WILSHIRE BLVD, SANTA MONICA, CA 90403-5610
(310) 892-0468
(310) 861-1888
Mailing address
1820 WILSHIRE BLVD, SANTA MONICA, CA 90403-5610
(310) 892-0468
(310) 861-1888
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
PHY 50343
CA
3336C0003X
Community/Retail Pharmacy
Primary
PHY 50343
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PHA465390
—
CA
01
—
PHY 50343
CAILFORNIA STATE BOARD OF PHARMACY
CA
Enumeration date
07/20/2010
Last updated
02/03/2015
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