Healthcare Provider Details

I. General information

NPI: 1891976551
Provider Name (Legal Business Name): LEDA YACOUBIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 PICO BLVD
SANTA MONICA CA
90405-1827
US

IV. Provider business mailing address

5028 SHIRLEY AVE
TARZANA CA
91356-4428
US

V. Phone/Fax

Practice location:
  • Phone: 310-450-7624
  • Fax:
Mailing address:
  • Phone: 818-514-6629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number047818
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: