Provider Demographics
NPI:1043249105
Name:FAIRMONT PHARMACY LLC
Entity type:Organization
Organization Name:FAIRMONT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BARNET
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:626-793-1188
Mailing Address - Street 1:50 BELLEFONTAINE ST
Mailing Address - Street 2:STE 103
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3132
Mailing Address - Country:US
Mailing Address - Phone:626-793-1188
Mailing Address - Fax:626-793-8414
Practice Address - Street 1:50 BELLEFONTAINE ST
Practice Address - Street 2:STE 103
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:626-793-1188
Practice Address - Fax:626-793-8414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
CAPHY327443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2116041OtherPK
CAPHA327440Medicaid
2116041OtherPK