MEDICARE: BLUE FALCON LLC

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

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	:	1689267692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE FALCON LLC

Provider Business Mailing Address
First Line	:	2505 ANTHEM VILLAGE DR STE E282
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-5505
Country	:	US
Telephone Number	:	702-209-3640
Fax Number	:	702-209-3641

Provider Business Practice Location Address
First Line	:	1235 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1708
Country	:	US
Telephone Number	:	702-209-3640
Fax Number	:	702-209-3641

Authorized Official
Title or Position	:	OWNER/ PHARMACY MANAGER
Name	:	UGONNA NNODIM
Credential	:	PHARMD
Telephone Number	:	702-209-3640

Provider Enumeration Date	:	02/19/2021
Last Update Date	:	02/23/2022

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