Healthcare Provider Details

I. General information

NPI: 1902350150
Provider Name (Legal Business Name): EAST LA PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4968 WHITTIER BLVD
LOS ANGELES CA
90022-3130
US

IV. Provider business mailing address

4968 WHITTIER BLVD
LOS ANGELES CA
90022-3130
US

V. Phone/Fax

Practice location:
  • Phone: 323-685-5039
  • Fax: 323-685-2840
Mailing address:
  • Phone: 323-685-5039
  • Fax: 323-685-2840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY54275
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE LOZANO
Title or Position: OFF. MNGR/ SECRETARY
Credential:
Phone: 323-685-5039