=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578220125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARLO NICOLE ANGELES SISON RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2021
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20700 AVALON BLVD STE 700
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90746-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-819-3012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20700 AVALON BLVD STE 700
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90746-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-819-3012
-----------------------------------------------------
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 | 85591
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------