MEDICARE: GLOBAL COMPOUNDING PHARMACY 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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY50713	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5643956	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1699031468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLOBAL COMPOUNDING PHARMACY LLC

Provider Business Mailing Address
First Line	:	1544 PURDUE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-3105
Country	:	US
Telephone Number	:	424-832-3421
Fax Number	:	424-832-3452

Provider Business Practice Location Address
First Line	:	1544 PURDUE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-3105
Country	:	US
Telephone Number	:	424-832-3421
Fax Number	:	424-832-3452

Authorized Official
Title or Position	:	OWNER
Name	:	DABO KABOV
Credential	:
Telephone Number	:	424-832-3421

Provider Enumeration Date	:	04/06/2012
Last Update Date	:	09/10/2012

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