Provider Demographics
NPI:1447243324
Name:BW ONE INC
Entity Type:Organization
Organization Name:BW ONE INC
Other - Org Name:BIG 1 PHARMACY LA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-617-7888
Mailing Address - Street 1:656 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2801
Mailing Address - Country:US
Mailing Address - Phone:213-617-7888
Mailing Address - Fax:213-617-7241
Practice Address - Street 1:656 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2802
Practice Address - Country:US
Practice Address - Phone:213-617-7888
Practice Address - Fax:213-617-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY536553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA503880Medicaid
2126411OtherPK
CAPHA503880Medicaid