Healthcare Provider Details

I. General information

NPI: 1619036043
Provider Name (Legal Business Name): EMERSON PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8610 S SEPULVEDA BLVD STE 108
LOS ANGELES CA
90045-4009
US

IV. Provider business mailing address

1702 S ROBERTSON BLVD # 152
LOS ANGELES CA
90035-4316
US

V. Phone/Fax

Practice location:
  • Phone: 310-670-3834
  • Fax: 310-670-4921
Mailing address:
  • Phone: 310-670-3834
  • Fax: 310-670-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY53692
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NIMA RODEFSHALOM
Title or Position: PRESIDENT
Credential:
Phone: 310-670-3834