Healthcare Provider Details

I. General information

NPI: 1164230512
Provider Name (Legal Business Name): LGDM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S CENTRAL AVE STE 101A
GLENDALE CA
91204-4375
US

IV. Provider business mailing address

800 S CENTRAL AVE STE 101A
GLENDALE CA
91204-4375
US

V. Phone/Fax

Practice location:
  • Phone: 818-319-3046
  • Fax:
Mailing address:
  • Phone: 818-319-3046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GARY JOHN GEVORKIAN
Title or Position: PIC
Credential: PHARM D
Phone: 818-853-2800