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General NPI Number Information
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NPI Number | 1104076884
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Entity Type | Organization
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Legal Business Name | BRAVO PHARMACY LLC
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Dates
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Enumeration Date | 09/30/2008
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Last Update Date | 11/15/2011
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Provider Practice Location Address
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Address Line | 10211 AVALON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90003-4819
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Country | US
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Telephone | 323-757-2727
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Fax | 323-575-2722
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Provider Business Mailing Address
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Address Line | 2275 TORRANCE BLVD SUITE101
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City | TORRANCE
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State | CA
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Zip | 90501-2550
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Country | US
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Telephone | 310-618-1988
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Fax | 310-618-1996
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Authorized Official
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Title or Position | CEO
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Name | SANG KIM
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Credential |
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Telephone | 310-618-1988
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY49276
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License Number State | CA
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