Provider Demographics
NPI:1497491070
Name:DICHOSO, BRYAN KEVIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEVIN
Last Name:DICHOSO
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 1:6705 FERRARA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-3719
Mailing Address - Country:US
Mailing Address - Phone:323-559-0036
Mailing Address - Fax:
Practice Address - Street 1:3010 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-4202
Practice Address - Country:US
Practice Address - Phone:310-478-9821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-07
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist