MEDICARE: BLACK PANDA LLC

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
2	333600000X	Pharmacy

General Provider Information

NPI Number	:	1518577741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK PANDA LLC

Provider Business Mailing Address
First Line	:	6280 S VALLEY VIEW BLVD STE 734
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-6833
Country	:	US
Telephone Number	:	702-219-6173
Fax Number	:

Provider Business Practice Location Address
First Line	:	2507 S STATE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-3109
Country	:	US
Telephone Number	:	855-558-2382
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	BARBARA DEINET
Credential	:
Telephone Number	:	702-219-6173

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	08/03/2020

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Directions to “BLACK PANDA LLC ” Practice Location

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