Provider Demographics
NPI:1679662357
Name:THE WILTON PHARMACY, INC
Entity type:Organization
Organization Name:THE WILTON PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEE KYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-731-0600
Mailing Address - Street 1:3511 W OLYMPIC BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3563
Mailing Address - Country:US
Mailing Address - Phone:323-731-0600
Mailing Address - Fax:323-731-9787
Practice Address - Street 1:3511 W OLYMPIC BLVD
Practice Address - Street 2:STE 102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3563
Practice Address - Country:US
Practice Address - Phone:323-731-0600
Practice Address - Fax:323-731-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY447843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA447840Medicaid
1993384OtherPK
CAPHA447840Medicaid