Healthcare Provider Details

I. General information

NPI: 1083063473
Provider Name (Legal Business Name): IVAN LAW RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 W PALMDALE BLVD # A
PALMDALE CA
93551-4232
US

IV. Provider business mailing address

540 W PALMDALE BLVD # A
PALMDALE CA
93551-4232
US

V. Phone/Fax

Practice location:
  • Phone: 661-267-2638
  • Fax: 661-267-0813
Mailing address:
  • Phone: 661-267-2638
  • Fax: 661-267-0813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number50725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: