=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609927847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DWCD CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4128 W BURBANK BLVD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-500-0079
-----------------------------------------------------
Fax | 818-500-0225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4128 W BURBANK BLVD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-500-0079
-----------------------------------------------------
Fax | 818-500-0225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. DONOVAN WALLACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-500-0079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 46287
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 46287
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 46287
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------