=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962168740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VG WELLNESS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2021
-----------------------------------------------------
Last Update Date | 11/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 S VERMONT AVE STE 109
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-388-4100
-----------------------------------------------------
Fax | 213-388-4200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 S VERMONT AVE STE 109
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-388-4100
-----------------------------------------------------
Fax | 213-388-4200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | KYUNGJOO KOO
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 818-279-5407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------