Healthcare Provider Details

I. General information

NPI: 1164262002
Provider Name (Legal Business Name): LUELLA MYRTLE VIEGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 BROAD AVE
WILMINGTON CA
90744-2604
US

IV. Provider business mailing address

1325 BROAD AVE
WILMINGTON CA
90744-2604
US

V. Phone/Fax

Practice location:
  • Phone: 310-404-2030
  • Fax:
Mailing address:
  • Phone: 310-404-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number65298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: