Healthcare Provider Details

I. General information

NPI: 1134105497
Provider Name (Legal Business Name): LEO'S CATALINA DRUG STORE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CRESCENT AVE.
AVALON CA
90704-1543
US

IV. Provider business mailing address

401 CRESCENT AVE
AVALON CA
90704-1543
US

V. Phone/Fax

Practice location:
  • Phone: 310-510-0189
  • Fax: 310-510-2585
Mailing address:
  • Phone: 310-510-0189
  • Fax: 310-510-2585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY46830
License Number StateCA

VIII. Authorized Official

Name: BRYCE NOLL
Title or Position: DIRECTOR
Credential:
Phone: 310-510-0189