MEDICARE: KNOLLS PHARMACY

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	3336C0003X	Community/Retail Pharmacy	PHY36924	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1994466	OTHER		PK

General Provider Information

NPI Number	:	1124157904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNOLLS PHARMACY

Provider Business Mailing Address
First Line	:	16630 MARQUEZ AVE
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3233
Country	:	US
Telephone Number	:	310-454-6000
Fax Number	:	310-454-0605

Provider Business Practice Location Address
First Line	:	16630 MARQUEZ AVE
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3233
Country	:	US
Telephone Number	:	310-454-6000
Fax Number	:	310-454-0605

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	MR. GORDON WONG
Credential	:	PHARMD
Telephone Number	:	310-454-6000

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	11/17/2017

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Directions to “KNOLLS PHARMACY ” Practice Location

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