Healthcare Provider Details

I. General information

NPI: 1306372891
Provider Name (Legal Business Name): BOLSA MEDICAL MTM PHARMA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6552 BOLSA AVE STE A
HUNTINGTON BEACH CA
92647-2656
US

IV. Provider business mailing address

6552 BOLSA AVE STE A
HUNTINGTON BEACH CA
92647-2660
US

V. Phone/Fax

Practice location:
  • Phone: 714-916-5383
  • Fax: 714-916-5384
Mailing address:
  • Phone: 714-916-5383
  • Fax: 714-916-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. TINA TUYET QUACH-TRAN
Title or Position: PRESIDENT / PHARMACIST IN CHARGE
Credential:
Phone: 714-916-5383