=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700897295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODYSTORE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 05/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 N HOLLYWOOD WAY STE 103
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-1026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-736-5828
-----------------------------------------------------
Fax | 818-736-5838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 370
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-0370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-736-5828
-----------------------------------------------------
Fax | 818-736-5838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JENSEN CHANG
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 818-736-5828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------