MEDICARE: MODERNHEALTH SPECIALTY (PX), 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5646863	OTHER		NCPDP

General Provider Information

NPI Number	:	1942541982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERNHEALTH SPECIALTY (PX), LLC

Provider Business Mailing Address
First Line	:	110 E HUNTINGTON DR
Second Line	:
City	:	MONROVIA
State	:	CA
Zip	:	91016-3415
Country	:	US
Telephone Number	:	626-932-1714
Fax Number	:

Provider Business Practice Location Address
First Line	:	7373 LINCOLN WAY
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92841-1428
Country	:	US
Telephone Number	:	800-228-3643
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/COO
Name	:	SHERRI CHERMAN
Credential	:	PHARM
Telephone Number	:	626-932-1603

Provider Enumeration Date	:	03/14/2013
Last Update Date	:	10/03/2013

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