MEDICARE: ALINE DERKALOSTIAN

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	67633	CA

General Provider Information

NPI Number	:	1477967255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALINE DERKALOSTIAN

Provider Business Mailing Address
First Line	:	759 AVENUE A
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-4813
Country	:	US
Telephone Number	:	714-803-8345
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 AVIATION BLVD
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-2810
Country	:	US
Telephone Number	:	310-376-4460
Fax Number	:

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

Provider Enumeration Date	:	06/19/2014
Last Update Date	:	06/19/2014

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