=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912233644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAVO PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2009
-----------------------------------------------------
Last Update Date | 05/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7316 COMPTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90001-2532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-586-9828
-----------------------------------------------------
Fax | 323-589-2174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7316 COMPTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90001-2532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-586-9828
-----------------------------------------------------
Fax | 323-589-2174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/PIC
-----------------------------------------------------
Name | MR. FRED K CHO
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 323-586-9828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY 53315
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------