MEDICARE: MARIPOSA PHARMACY LTD

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	PHY52570	CA

General Provider Information

NPI Number	:	1861889735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIPOSA PHARMACY LTD

Provider Business Mailing Address
First Line	:	2970 W OLYMPIC BLVD # 104
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2518
Country	:	US
Telephone Number	:	213-365-5067
Fax Number	:

Provider Business Practice Location Address
First Line	:	2970 W OLYMPIC BLVD # 104
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2518
Country	:	US
Telephone Number	:	213-365-5067
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BILL PARK
Credential	:
Telephone Number	:	310-720-1237

Provider Enumeration Date	:	04/18/2015
Last Update Date	:	04/18/2015

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