Basic Information
| Provider Information | |||||||||
| NPI: | 1740547868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANGEMI | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | NGOC-TA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TA | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | NGOC | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARM.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11301 WILSHIRE BLVD. (119) | ||||||||
| Address2: | BUILDING 500 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD. (119) | ||||||||
| Address2: | BUILDING 500 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2012 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 67655 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.