=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710413703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUMINATE HEALTH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 06/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3948 PECK RD UNIT A9
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-2255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-522-1013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3948 PECK RD UNIT A9
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-2255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-522-1013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. LILIA XU
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 626-522-1013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------