Healthcare Provider Details

I. General information

NPI: 1679298129
Provider Name (Legal Business Name): ALYSSA GBEWONYO PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11606 SEMINOLE CIR
PORTER RANCH CA
91326-1422
US

IV. Provider business mailing address

11606 SEMINOLE CIR
PORTER RANCH CA
91326-1422
US

V. Phone/Fax

Practice location:
  • Phone: 818-317-9829
  • Fax:
Mailing address:
  • Phone: 818-317-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number86640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: