Provider Demographics
NPI:1861084329
Name:IWATA, BRANDON MASUO
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MASUO
Last Name:IWATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 STAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4527
Mailing Address - Country:US
Mailing Address - Phone:626-319-1472
Mailing Address - Fax:
Practice Address - Street 1:222 N MARKET ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1217
Practice Address - Country:US
Practice Address - Phone:310-671-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty