Healthcare Provider Details

I. General information

NPI: 1063597326
Provider Name (Legal Business Name): EASYMED PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1367 FOOTHILL BLVD
LA CANADA CA
91011-2183
US

IV. Provider business mailing address

1367 FOOTHILL BLVD
LA CANADA CA
91011-2183
US

V. Phone/Fax

Practice location:
  • Phone: 818-766-5376
  • Fax: 818-766-9736
Mailing address:
  • Phone: 818-766-5376
  • Fax: 818-766-9736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY38122
License Number StateCA

VIII. Authorized Official

Name: MIKIA AIVAZE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 818-766-5376