MEDICARE: NANOOM PHARMACY, 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	:	1588330617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NANOOM PHARMACY, INC.

Provider Business Mailing Address
First Line	:	4301 S FIGUEROA ST STE E
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2671
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 S FIGUEROA ST STE E
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2671
Country	:	US
Telephone Number	:	213-459-5900
Fax Number	:	213-459-5902

Authorized Official
Title or Position	:	OWNER
Name	:	KYUNGSIG CHOI
Credential	:
Telephone Number	:	213-459-5900

Provider Enumeration Date	:	08/18/2021
Last Update Date	:	09/16/2021

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