MEDICARE: DWCD CORP

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	332B00000X	Durable Medical Equipment & Medical Supplies	46287	CA
2	3336C0004X	Compounding Pharmacy	46287	CA
3	3336C0003X	Community/Retail Pharmacy	46287	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609927847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWCD CORP

Provider Business Mailing Address
First Line	:	4128 W BURBANK BLVD
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-2121
Country	:	US
Telephone Number	:	818-500-0079
Fax Number	:	818-500-0225

Provider Business Practice Location Address
First Line	:	4128 W BURBANK BLVD
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-2121
Country	:	US
Telephone Number	:	818-500-0079
Fax Number	:	818-500-0225

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MR. DONOVAN WALLACE
Credential	:
Telephone Number	:	818-500-0079

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	02/04/2020

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Directions to “DWCD CORP ” Practice Location

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