=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811125198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST COAST MEDICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2009
-----------------------------------------------------
Last Update Date | 08/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8777 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-335-0520
-----------------------------------------------------
Fax | 424-335-0521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8777 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-335-0520
-----------------------------------------------------
Fax | 424-335-0521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARK KOVINSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 424-335-0520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY53839
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------