Healthcare Provider Details

I. General information

NPI: 1013908458
Provider Name (Legal Business Name): MID WILSHIRE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6317 WILSHIRE BLVD
LOS ANGELES CA
90048-5602
US

IV. Provider business mailing address

6317 WILSHIRE BLVD
LOS ANGELES CA
90048-5602
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-6080
  • Fax: 323-653-2503
Mailing address:
  • Phone: 323-653-6080
  • Fax: 323-653-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY36001
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN GONG
Title or Position: PHARMACIST
Credential: PHARM. D.
Phone: 323-653-6080