Provider Demographics
NPI:1669219952
Name:ILAO, PATRICIA MAE BULOSAN (PHARMD)
Entity type:Individual
Prefix:
First Name:PATRICIA MAE
Middle Name:BULOSAN
Last Name:ILAO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 COURSER AVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1420
Mailing Address - Country:US
Mailing Address - Phone:562-458-4989
Mailing Address - Fax:
Practice Address - Street 1:316 S PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3729
Practice Address - Country:US
Practice Address - Phone:310-540-9183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist