MEDICARE: SGV COMPOUNDING PHARMACY INC

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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy	PHY50946	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2134361	OTHER		PK

General Provider Information

NPI Number	:	1023377504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SGV COMPOUNDING PHARMACY INC

Provider Business Mailing Address
First Line	:	5610 1/2 ROSEMEAD BLVD
Second Line	:
City	:	TEMPLE CITY
State	:	CA
Zip	:	91780-1849
Country	:	US
Telephone Number	:	626-291-5014
Fax Number	:	626-291-5695

Provider Business Practice Location Address
First Line	:	5610 1/2 ROSEMEAD BLVD
Second Line	:
City	:	TEMPLE CITY
State	:	CA
Zip	:	91780-1849
Country	:	US
Telephone Number	:	626-291-5014
Fax Number	:	626-291-5695

Authorized Official
Title or Position	:	OWNER
Name	:	PHILIP CHEUNG
Credential	:
Telephone Number	:	626-757-8675

Provider Enumeration Date	:	05/03/2012
Last Update Date	:	07/31/2013

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