Healthcare Provider Details

I. General information

NPI: 1114686912
Provider Name (Legal Business Name): MARINE MANANYAN GYULBEKYAN PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6727 ODESSA AVE # 201
LAKE BALBOA CA
91406-5747
US

IV. Provider business mailing address

6727 ODESSA AVE # 201
LAKE BALBOA CA
91406-5747
US

V. Phone/Fax

Practice location:
  • Phone: 818-743-4373
  • Fax:
Mailing address:
  • Phone: 818-743-4373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number80705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: