MEDICARE: ALISA KUSOLVISITKUL PHARMD

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	183500000X	Pharmacist	051.293807	IL
2	183500000X	Pharmacist	PHA66994	CA

General Provider Information

NPI Number	:	1912288945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISA KUSOLVISITKUL PHARMD

Provider Business Mailing Address
First Line	:	1902 MARENGO ST STE 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1378
Country	:	US
Telephone Number	:	323-405-0417
Fax Number	:

Provider Business Practice Location Address
First Line	:	1902 MARENGO ST STE 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1378
Country	:	US
Telephone Number	:	323-405-0417
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2011
Last Update Date	:	12/26/2022

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