Healthcare Provider Details

I. General information

NPI: 1316577950
Provider Name (Legal Business Name): EDISON LAWRENCE OLIVA ESCOBAR PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 CADILLAC AVE
LOS ANGELES CA
90034-1702
US

IV. Provider business mailing address

3280 E FOOTHILL BLVD
PASADENA CA
91107-3103
US

V. Phone/Fax

Practice location:
  • Phone: 866-391-2673
  • Fax:
Mailing address:
  • Phone: 866-248-1408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number85988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: