Provider Demographics
NPI:1700897295
Name:BODYSTORE INC
Entity Type:Organization
Organization Name:BODYSTORE INC
Other - Org Name:HOSPICARE PHARMACY LOS ANGELES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:818-736-5828
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-0370
Mailing Address - Country:US
Mailing Address - Phone:818-736-5828
Mailing Address - Fax:818-736-5838
Practice Address - Street 1:3000 N HOLLYWOOD WAY STE 103
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-1026
Practice Address - Country:US
Practice Address - Phone:818-736-5828
Practice Address - Fax:818-736-5838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997864OtherPK
CAPHA46900Medicaid
4808570001Medicare NSC