Healthcare Provider Details

I. General information

NPI: 1740653880
Provider Name (Legal Business Name): ALIDZ TALATINIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 COUNTRY CLUB DR SUITE C
SIMI VALLEY CA
93065-7691
US

IV. Provider business mailing address

591 COUNTRY CLUB DR SUITE C
SIMI VALLEY CA
93065-7691
US

V. Phone/Fax

Practice location:
  • Phone: 805-584-2035
  • Fax: 805-584-2447
Mailing address:
  • Phone: 805-584-2035
  • Fax: 805-584-2447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number69072
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: