=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104132463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOUGRA BOUNACDARY PHRAMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2010
-----------------------------------------------------
Last Update Date | 08/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 CHERRY AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90802-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-951-1360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1912 N BRITTON DR
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90815-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-394-6990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 57762
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------