Healthcare Provider Details

I. General information

NPI: 1295286284
Provider Name (Legal Business Name): THEODORE MARTENS SIEVERS PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ ROOM 8318
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

1010 VETERAN AVE ROOM 1232
LOS ANGELES CA
90024-2704
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-7832
  • Fax:
Mailing address:
  • Phone: 310-794-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number48398
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number48398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: