Healthcare Provider Details

I. General information

NPI: 1073729927
Provider Name (Legal Business Name): CLYDE CASSEL R. PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 E CARSON ST
CARSON CA
90745-2720
US

IV. Provider business mailing address

645 E CARSON ST
CARSON CA
90745-2720
US

V. Phone/Fax

Practice location:
  • Phone: 310-597-6991
  • Fax: 310-830-2979
Mailing address:
  • Phone: 310-597-6991
  • Fax: 310-830-2979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number35717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: