Provider Demographics
NPI:1386257525
Name:KALLO, BASSAM (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:
Last Name:KALLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2514
Mailing Address - Country:US
Mailing Address - Phone:818-763-5562
Mailing Address - Fax:818-763-5767
Practice Address - Street 1:12100 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2514
Practice Address - Country:US
Practice Address - Phone:818-763-5562
Practice Address - Fax:818-763-5767
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist