MEDICARE: INFORTEL MEDICAL GROUP

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	333600000X	Pharmacy	PHY 50343	CA
2	3336C0003X	Community/Retail Pharmacy	PHY 50343	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
2	PHY 50343	OTHER	CA	CAILFORNIA STATE BOARD OF PHARMACY

General Provider Information

NPI Number	:	1780997619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INFORTEL MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1820 WILSHIRE BLVD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5610
Country	:	US
Telephone Number	:	310-892-0468
Fax Number	:	310-861-1888

Provider Business Practice Location Address
First Line	:	1820 WILSHIRE BLVD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5610
Country	:	US
Telephone Number	:	310-892-0468
Fax Number	:	310-861-1888

Authorized Official
Title or Position	:	PRESIDENT/PIC
Name	:	MS. ELEANOR FAM MAI KONG
Credential	:	PHARM D
Telephone Number	:	310-892-0468

Provider Enumeration Date	:	07/20/2010
Last Update Date	:	02/03/2015

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