Healthcare Provider Details

I. General information

NPI: 1790049484
Provider Name (Legal Business Name): PETICUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 S LA CIENEGA BLVD # 102
LOS ANGELES CA
90035-4670
US

IV. Provider business mailing address

1804 S LA CIENEGA BLVD # 102
LOS ANGELES CA
90035-4670
US

V. Phone/Fax

Practice location:
  • Phone: 310-839-7387
  • Fax: 310-288-9141
Mailing address:
  • Phone: 310-839-7387
  • Fax: 310-288-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RABIN SHAOULIAN
Title or Position: LOCATION MANAGER
Credential:
Phone: 310-839-7387