Healthcare Provider Details

I. General information

NPI: 1609927847
Provider Name (Legal Business Name): DWCD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 W BURBANK BLVD
BURBANK CA
91505-2121
US

IV. Provider business mailing address

4128 W BURBANK BLVD
BURBANK CA
91505-2121
US

V. Phone/Fax

Practice location:
  • Phone: 818-500-0079
  • Fax: 818-500-0225
Mailing address:
  • Phone: 818-500-0079
  • Fax: 818-500-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number46287
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number46287
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number46287
License Number StateCA

VIII. Authorized Official

Name: MR. DONOVAN WALLACE
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 818-500-0079