Healthcare Provider Details

I. General information

NPI: 1295731057
Provider Name (Legal Business Name): DE LA STAR PHARMACY,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 W MAGNOLIA BLVD
BURBANK CA
91506-1839
US

IV. Provider business mailing address

1721 W MAGNOLIA BLVD
BURBANK CA
91506-1839
US

V. Phone/Fax

Practice location:
  • Phone: 818-566-7262
  • Fax: 818-566-7500
Mailing address:
  • Phone: 818-566-7262
  • Fax: 818-566-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number452190
License Number StateCA

VIII. Authorized Official

Name: MRS. AREGNAZ FAYROYAN
Title or Position: CEO / OWNER
Credential:
Phone: 818-566-7262