Healthcare Provider Details

I. General information

NPI: 1245941848
Provider Name (Legal Business Name): REGENTS UNIV OF CALIF LOS ANGELES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UCLA MEDICAL PLZ STE 130
LOS ANGELES CA
90095-8344
US

IV. Provider business mailing address

757 WESTWOOD PLZ # B531
LOS ANGELES CA
90095-8358
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-8503
  • Fax:
Mailing address:
  • Phone: 310-267-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY LEHR WALLACE
Title or Position: CFO
Credential:
Phone: 310-794-8627