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NPI Code Detail

MEDICARE: PROVIDENCE PHARMACEUTICALS INC

MEDICARE: PROVIDENCE PHARMACEUTICALS 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
1333600000XPharmacy
23336C0003XCommunity/Retail PharmacyPHY51680CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12143869OTHERPK

General Provider Information

NPI Number : 1639180227
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROVIDENCE PHARMACEUTICALS INC
Provider Business Mailing Address
First Line : 15435 S WESTERN AVE
Second Line : STE 100 C
City : GARDENA
State : CA
Zip : 90249-4323
Country : US
Telephone Number : 310-353-2695
Fax Number : 310-353-2696
Provider Business Practice Location Address
First Line : 15435 S WESTERN AVE
Second Line : STE 100 C
City : GARDENA
State : CA
Zip : 90249-4323
Country : US
Telephone Number : 310-353-2695
Fax Number : 310-353-2696
Authorized Official
Title or Position : PRESIDENT
Name : DIANA CHOI
Credential :
Telephone Number : 310-353-2699
Provider Enumeration Date : 08/10/2006
Last Update Date : 02/21/2017

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Directions to “PROVIDENCE PHARMACEUTICALS INC ” Practice Location

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