=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568193027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLE PHUONGANH LEQUANG PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2022
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2425 PORTER ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90021-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-545-6464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14380 TELLURIDE DR
-----------------------------------------------------
City | BALDWIN PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91706-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-646-8061
-----------------------------------------------------
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 | 85735
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------