MEDICARE: MR. STANLEY WILLIAM GOLDENBERG RPH

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	25720	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHARMACIST LICENSE #	OTHER	CA	25720

General Provider Information

NPI Number	:	1225057748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STANLEY WILLIAM GOLDENBERG RPH

Provider Business Mailing Address
First Line	:	10625 LEVICO WAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1902
Country	:	US
Telephone Number	:	310-456-6867
Fax Number	:	310-476-1211

Provider Business Practice Location Address
First Line	:	10625 LEVICO WAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1902
Country	:	US
Telephone Number	:	310-456-6867
Fax Number	:	310-476-1211

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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