Healthcare Provider Details

I. General information

NPI: 1245338276
Provider Name (Legal Business Name): BEVERLY GLEN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 N BEVERLY GLEN CIR
LOS ANGELES CA
90077-1724
US

IV. Provider business mailing address

2946 N BEVERLY GLEN CIR
LOS ANGELES CA
90077-1724
US

V. Phone/Fax

Practice location:
  • Phone: 310-475-0568
  • Fax: 310-475-5478
Mailing address:
  • Phone: 310-475-0568
  • Fax: 310-475-5478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY55866
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ADAM MICHAEL BURMAN
Title or Position: PRESIDENT
Credential:
Phone: 310-475-0568