Healthcare Provider Details

I. General information

NPI: 1235897331
Provider Name (Legal Business Name): LGDM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
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: 818-853-2880
  • Fax: 818-853-2881
Mailing address:
  • Phone: 818-853-2880
  • Fax: 818-853-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GARY GEVORKIAN
Title or Position: OWNER
Credential:
Phone: 818-853-2880