MEDICARE: LA BREA RX INC

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

General Provider Information

NPI Number	:	1407637044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA BREA RX INC

Provider Business Mailing Address
First Line	:	4314 W SLAUSON AVE FL 1
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-2853
Country	:	US
Telephone Number	:	323-705-5702
Fax Number	:

Provider Business Practice Location Address
First Line	:	4314 W SLAUSON AVE FL 1
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-2853
Country	:	US
Telephone Number	:	323-705-5702
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GERSHON KOHANBASH
Credential	:
Telephone Number	:	323-705-5702

Provider Enumeration Date	:	10/10/2023
Last Update Date	:	10/10/2023

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Directions to “LA BREA RX INC ” Practice Location

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