Provider Demographics
NPI:1760876528
Name:BRUCCOLERI, MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BRUCCOLERI
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 1:317 GARNET ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3368
Mailing Address - Country:US
Mailing Address - Phone:310-937-9117
Mailing Address - Fax:
Practice Address - Street 1:1100 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3951
Practice Address - Country:US
Practice Address - Phone:310-374-2435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH29557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist