MEDICARE: BROTHERS PHARMACY, 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

General Provider Information

NPI Number	:	1982142055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROTHERS PHARMACY, LLC

Provider Business Mailing Address
First Line	:	5243 W CHARLESTON BLVD STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1304
Country	:	US
Telephone Number	:	702-678-6267
Fax Number	:

Provider Business Practice Location Address
First Line	:	5243 W CHARLESTON BLVD STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1304
Country	:	US
Telephone Number	:	702-678-6267
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGING MEMBER
Name	:	MICHAEL AGWARA
Credential	:
Telephone Number	:	702-678-6267

Provider Enumeration Date	:	02/08/2017
Last Update Date	:	02/08/2017

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