Healthcare Provider Details

I. General information

NPI: 1588665087
Provider Name (Legal Business Name): VAKO MINAS AGAJANIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 E WASHINGTON BLVD
PASADENA CA
91104-2752
US

IV. Provider business mailing address

1729 E WASHINGTON BLVD
PASADENA CA
91104-2752
US

V. Phone/Fax

Practice location:
  • Phone: 626-817-9828
  • Fax: 626-817-9830
Mailing address:
  • Phone: 626-817-9828
  • Fax: 626-817-9830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number53780
License Number StateCA

VIII. Authorized Official

Name: VAKO AGAJANIAN
Title or Position: OWNER
Credential:
Phone: 626-817-9828