Healthcare Provider Details

I. General information

NPI: 1427701069
Provider Name (Legal Business Name): ROSSEN OKOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 03/09/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 HEALTH SCIENCES DR
LA JOLLA CA
92093-1503
US

IV. Provider business mailing address

3855 HEALTH SCIENCES DR
SAN DIEGO CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 617-642-4334
  • Fax:
Mailing address:
  • Phone: 858-822-6095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number77205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: