Healthcare Provider Details

I. General information

NPI: 1609753334
Provider Name (Legal Business Name): MARIAN MARTHA DEPATILLO TAN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S ATLANTIC BLVD
LOS ANGELES CA
90022-3211
US

IV. Provider business mailing address

1943 W 29TH ST
LONG BEACH CA
90810-2906
US

V. Phone/Fax

Practice location:
  • Phone: 323-825-8256
  • Fax: 323-825-8358
Mailing address:
  • Phone: 323-825-8256
  • Fax: 323-825-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number91483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: