MEDICARE: MANUEL DEGRACIA IDIO JR.

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	183500000X	Pharmacist	60425	CA

General Provider Information

NPI Number	:	1174936397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANUEL DEGRACIA IDIO JR.

Provider Business Mailing Address
First Line	:	6130 W. SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028
Country	:	US
Telephone Number	:	323-467-4201
Fax Number	:	323-467-3550

Provider Business Practice Location Address
First Line	:	6130 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-6424
Country	:	US
Telephone Number	:	323-467-4201
Fax Number	:	323-467-3550

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2014
Last Update Date	:	06/05/2014

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