=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275042459
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELONG PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15415 JEFFREY RD STE 108
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-988-3998
-----------------------------------------------------
Fax | 949-988-3996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15415 JEFFREY RD STE 108
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-988-3998
-----------------------------------------------------
Fax | 949-988-3996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PIC
-----------------------------------------------------
Name | MR. RUI CUI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-988-3998
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 55621
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------