Healthcare Provider Details

I. General information

NPI: 1669781043
Provider Name (Legal Business Name): USC I.D.S. PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVE STE 2407
LOS ANGELES CA
90089-0112
US

IV. Provider business mailing address

1441 EASTLAKE AVE SUITE 2407
LOS ANGELES CA
90089-0112
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-3538
  • Fax: 323-865-0857
Mailing address:
  • Phone: 323-865-3538
  • Fax: 323-865-0857

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY 50231
License Number StateCA

VIII. Authorized Official

Name: SCOTT EVANS
Title or Position: C.O.O
Credential:
Phone: 323-442-8677