Healthcare Provider Details

I. General information

NPI: 1225610710
Provider Name (Legal Business Name): ROQUEBULILAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 HILLHURST AVE
LOS ANGELES CA
90027
US

IV. Provider business mailing address

1905 HILLHURST AVE
LOS ANGELES CA
90027
US

V. Phone/Fax

Practice location:
  • Phone: 323-573-3439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROSELYN ROQUE
Title or Position: SECRETARY
Credential: PHARMACIST
Phone: 323-522-3893