Healthcare Provider Details

I. General information

NPI: 1871497404
Provider Name (Legal Business Name): LUCKY 888 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 E BONANZA RD STE 6
LAS VEGAS NV
89110-3455
US

IV. Provider business mailing address

4880 E BONANZA RD STE 6
LAS VEGAS NV
89110-3455
US

V. Phone/Fax

Practice location:
  • Phone: 702-881-1099
  • Fax: 702-850-8900
Mailing address:
  • Phone: 702-881-1099
  • Fax: 702-850-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT BRYAN JOSE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 702-881-1099