=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083973127
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT MICHAEL SMALL REGISTERED PHARMACIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2012
-----------------------------------------------------
Last Update Date | 05/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 UCLS MEDICAL PLAZA, SUITE 135 LEVEL ONE UCLA MEDICAL PLAZA PHARMACY
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-6949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-794-1176
-----------------------------------------------------
Fax | 310-794-1187
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 UCLS MEDICAL PLAZA, SUITE 135 LEVEL ONE UCLA MEDICAL PLAZA PHARMACY
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-6949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-794-1176
-----------------------------------------------------
Fax | 310-794-1187
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 24709
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 138342-1701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------