MEDICARE: MAYERLING PHARMACY, INC

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	3336C0003X	Community/Retail Pharmacy	54346	CA

General Provider Information

NPI Number	:	1669833695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYERLING PHARMACY, INC

Provider Business Mailing Address
First Line	:	213 N ORANGE ST
Second Line	:	SUITE C
City	:	GLENDALE
State	:	CA
Zip	:	91203-2648
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 N ORANGE ST
Second Line	:	SUITE C
City	:	GLENDALE
State	:	CA
Zip	:	91203-2648
Country	:	US
Telephone Number	:	747-221-7663
Fax Number	:

Authorized Official
Title or Position	:	CEO/PIC
Name	:	NAREK DERHARTUNIAN
Credential	:
Telephone Number	:	747-221-7663

Provider Enumeration Date	:	03/18/2016
Last Update Date	:	03/18/2016

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