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General NPI Number Information
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NPI Number | 1407331002
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Entity Type | Organization
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Legal Business Name | MID-WILSHIRE HEALTH INC
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Dates
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Enumeration Date | 09/28/2018
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Last Update Date | 09/28/2018
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Provider Practice Location Address
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Address Line | 1809 VERDUGO BLVD STE 110
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City | GLENDALE
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State | CA
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Zip | 91208-1402
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Country | US
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Telephone | 818-928-1304
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Fax |
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Provider Business Mailing Address
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Address Line | 2106 YOSEMITE DR
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City | LOS ANGELES
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State | CA
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Zip | 90041-2702
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Country | US
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Telephone | 310-780-0735
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SAMUEL GONG
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Credential | PHARM D
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Telephone | 310-780-0735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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