Provider Demographics
NPI:1912233644
Name:BRAVO PHARMACY LLC
Entity Type:Organization
Organization Name:BRAVO PHARMACY LLC
Other - Org Name:BRAVO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:323-586-9828
Mailing Address - Street 1:7316 COMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2532
Mailing Address - Country:US
Mailing Address - Phone:323-586-9828
Mailing Address - Fax:323-589-2174
Practice Address - Street 1:7316 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-2532
Practice Address - Country:US
Practice Address - Phone:323-586-9828
Practice Address - Fax:323-589-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 533153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912233644Medicaid
5636343OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHY 53315OtherSTATE BOARD OF PHARMACY PERMIT