MEDICARE: VILLAGE ROSE PHARMACY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	51983	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2150593	OTHER		PK

General Provider Information

NPI Number	:	1043603780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE ROSE PHARMACY, INC.

Provider Business Mailing Address
First Line	:	7773 UNIVERSITY AVE
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-4950
Country	:	US
Telephone Number	:	619-741-1344
Fax Number	:	619-741-1322

Provider Business Practice Location Address
First Line	:	7773 UNIVERSITY AVE
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-4950
Country	:	US
Telephone Number	:	619-741-1344
Fax Number	:	619-741-1322

Authorized Official
Title or Position	:	OWNER
Name	:	LORELEI NGUYEN
Credential	:
Telephone Number	:	619-750-8101

Provider Enumeration Date	:	03/05/2015
Last Update Date	:	03/05/2015

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