MEDICARE: BRAVO 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	PHY49276	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5632422	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1104076884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVO PHARMACY LLC

Provider Business Mailing Address
First Line	:	2275 TORRANCE BLVD
Second Line	:	SUITE101
City	:	TORRANCE
State	:	CA
Zip	:	90501-2550
Country	:	US
Telephone Number	:	310-618-1988
Fax Number	:	310-618-1996

Provider Business Practice Location Address
First Line	:	10211 AVALON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90003-4819
Country	:	US
Telephone Number	:	323-757-2727
Fax Number	:	323-575-2722

Authorized Official
Title or Position	:	CEO
Name	:	SANG KIM
Credential	:
Telephone Number	:	310-618-1988

Provider Enumeration Date	:	09/30/2008
Last Update Date	:	11/15/2011

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Directions to “BRAVO PHARMACY LLC ” Practice Location

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