Provider Demographics
NPI:1487795340
Name:BRIGHTON WAY PHARMACY
Entity type:Organization
Organization Name:BRIGHTON WAY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:YEPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-651-1595
Mailing Address - Street 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5702
Mailing Address - Country:US
Mailing Address - Phone:323-651-1595
Mailing Address - Fax:323-951-1095
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5702
Practice Address - Country:US
Practice Address - Phone:323-651-1595
Practice Address - Fax:323-951-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY379493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0575805OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1061470001Medicare NSC