Healthcare Provider Details

I. General information

NPI: 1609974005
Provider Name (Legal Business Name): BWWNGC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7824 GIRARD AVE
LA JOLLA CA
92037-4230
US

IV. Provider business mailing address

7824 GIRARD AVE
LA JOLLA CA
92037-4230
US

V. Phone/Fax

Practice location:
  • Phone: 858-459-4285
  • Fax: 858-459-9521
Mailing address:
  • Phone: 858-459-4285
  • Fax: 858-459-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY37018
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. WAYNE WOODS
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 858-459-4285