MEDICARE: WILTOH PHARMACY

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

Other Identifiers

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

General Provider Information

NPI Number	:	1770536252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILTOH PHARMACY

Provider Business Mailing Address
First Line	:	3511 W OLYMPIC BLVD
Second Line	:	102
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3563
Country	:	US
Telephone Number	:	323-731-0600
Fax Number	:	323-731-9787

Provider Business Practice Location Address
First Line	:	3511 W OLYMPIC BLVD
Second Line	:	102
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3563
Country	:	US
Telephone Number	:	323-731-0600
Fax Number	:	323-731-9787

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. JUNG S KIM
Credential	:
Telephone Number	:	323-731-0600

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	08/22/2020

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1316139223 — JAMES M JUNG
Practice Location Address:

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Directions to “WILTOH PHARMACY ” Practice Location

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