Healthcare Provider Details

I. General information

NPI: 1154084036
Provider Name (Legal Business Name): LIANA GEVORGYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 FOOTHILL BLVD
LA CANADA CA
91011-3403
US

IV. Provider business mailing address

6726 SYLMAR AVE APT 106
VAN NUYS CA
91405-5137
US

V. Phone/Fax

Practice location:
  • Phone: 818-790-5577
  • Fax:
Mailing address:
  • Phone: 818-517-4642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number85399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: