=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881600476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1631 MONTANA AVE PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 04/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1631 MONTANA AVE
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-393-0761
-----------------------------------------------------
Fax | 310-395-6654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1631 MONTANA AVE
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-393-0761
-----------------------------------------------------
Fax | 310-395-6654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | MS. ELEANOR KONG
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 310-393-0761
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY 49018
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------