Healthcare Provider Details

I. General information

NPI: 1508184789
Provider Name (Legal Business Name): DR IKE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11736 VENTURA BLVD
STUDIO CITY CA
91604-2615
US

IV. Provider business mailing address

11736 VENTURA BLVD
STUDIO CITY CA
91604-2615
US

V. Phone/Fax

Practice location:
  • Phone: 818-980-3311
  • Fax: 818-980-3735
Mailing address:
  • Phone: 818-980-3311
  • Fax: 818-980-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50263
License Number StateCA

VIII. Authorized Official

Name: AYK DZHRAGATSPANYAN
Title or Position: PRES/PIC
Credential:
Phone: 818-419-2514