MEDICARE: JOSEPHINE PHARMACY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003500158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSEPHINE PHARMACY, LLC

Provider Business Mailing Address
First Line	:	6013 COTTONTAIL COVE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-1352
Country	:	US
Telephone Number	:	702-480-6221
Fax Number	:

Provider Business Practice Location Address
First Line	:	2013 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2056
Country	:	US
Telephone Number	:	702-403-1118
Fax Number	:	702-403-1108

Authorized Official
Title or Position	:	MANAGING PHARMACIST
Name	:	OBIAGELI LISA MOMODU
Credential	:	PHARMD
Telephone Number	:	702-480-6221

Provider Enumeration Date	:	06/02/2023
Last Update Date	:	09/12/2023

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Directions to “JOSEPHINE PHARMACY, LLC ” Practice Location

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