MEDICARE: EDWIN PARK

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	91651	CA

General Provider Information

NPI Number	:	1356204630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWIN PARK

Provider Business Mailing Address
First Line	:	3960 PENNSYLVANIA AVE UNIT 115
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91214-3788
Country	:	US
Telephone Number	:	818-967-9799
Fax Number	:

Provider Business Practice Location Address
First Line	:	11000 WHITE ROCK RD
Second Line	:
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-6010
Country	:	US
Telephone Number	:	800-977-2273
Fax Number	:

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

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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Directions to “ EDWIN PARK ” Practice Location

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