MEDICARE: JELICA PETROVIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	60537	CA

General Provider Information

NPI Number	:	1346679883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JELICA PETROVIC

Provider Business Mailing Address
First Line	:	3237 PROVON LN
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2714
Country	:	US
Telephone Number	:	310-466-4007
Fax Number	:

Provider Business Practice Location Address
First Line	:	3237 PROVON LN
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2714
Country	:	US
Telephone Number	:	310-466-4007
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/05/2013

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Directions to “ JELICA PETROVIC ” Practice Location

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