Healthcare Provider Details

I. General information

NPI: 1801512934
Provider Name (Legal Business Name): ANDREW THOMAS BLANCO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 KEESHEN DR
LOS ANGELES CA
90066-4509
US

IV. Provider business mailing address

1625 SCHRADER BLVD
LOS ANGELES CA
90028-6213
US

V. Phone/Fax

Practice location:
  • Phone: 310-420-1053
  • Fax:
Mailing address:
  • Phone: 323-993-7513
  • Fax: 323-308-4444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number86355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: