MEDICARE: EMERSON 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	3336C0004X	Compounding Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY53692	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992617	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619036043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERSON PHARMACY INC

Provider Business Mailing Address
First Line	:	1702 S ROBERTSON BLVD # 152
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4316
Country	:	US
Telephone Number	:	310-670-3834
Fax Number	:	310-670-4921

Provider Business Practice Location Address
First Line	:	8610 S SEPULVEDA BLVD STE 108
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4009
Country	:	US
Telephone Number	:	310-670-3834
Fax Number	:	310-670-4921

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NIMA RODEFSHALOM
Credential	:
Telephone Number	:	310-670-3834

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	10/12/2016

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Directions to “EMERSON PHARMACY INC ” Practice Location

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