Healthcare Provider Details

I. General information

NPI: 1386257525
Provider Name (Legal Business Name): BASSAM KALLO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 VENTURA BLVD
STUDIO CITY CA
91604-2514
US

IV. Provider business mailing address

12100 VENTURA BLVD
STUDIO CITY CA
91604-2514
US

V. Phone/Fax

Practice location:
  • Phone: 818-763-5562
  • Fax: 818-763-5767
Mailing address:
  • Phone: 818-763-5562
  • Fax: 818-763-5767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number82843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: