MEDICARE: BODYSTORE 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	3336L0003X	Long Term Care Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1997864	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700897295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODYSTORE INC

Provider Business Mailing Address
First Line	:	PO BOX 370
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-0370
Country	:	US
Telephone Number	:	818-736-5828
Fax Number	:	818-736-5838

Provider Business Practice Location Address
First Line	:	3000 N HOLLYWOOD WAY STE 103
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-1026
Country	:	US
Telephone Number	:	818-736-5828
Fax Number	:	818-736-5838

Authorized Official
Title or Position	:	CEO
Name	:	JENSEN CHANG
Credential	:	PHARM.D.
Telephone Number	:	818-736-5828

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	05/23/2019

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Directions to “BODYSTORE INC ” Practice Location

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