Healthcare Provider Details

I. General information

NPI: 1609152297
Provider Name (Legal Business Name): JIMSON BACOLOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W CARSON ST
CARSON CA
90745-2602
US

IV. Provider business mailing address

141 W CARSON ST
CARSON CA
90745-2602
US

V. Phone/Fax

Practice location:
  • Phone: 424-280-3022
  • Fax: 424-264-5607
Mailing address:
  • Phone: 424-280-3022
  • Fax: 424-264-5607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number56767
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number56767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: