Provider Demographics
NPI:1104076884
Name:BRAVO PHARMACY LLC
Entity type:Organization
Organization Name:BRAVO PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-618-1988
Mailing Address - Street 1:2275 TORRANCE BLVD
Mailing Address - Street 2:SUITE101
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2550
Mailing Address - Country:US
Mailing Address - Phone:310-618-1988
Mailing Address - Fax:310-618-1996
Practice Address - Street 1:10211 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-4819
Practice Address - Country:US
Practice Address - Phone:323-757-2727
Practice Address - Fax:323-575-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY492763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5632422OtherNCPDP PROVIDER IDENTIFICATION NUMBER