Healthcare Provider Details

I. General information

NPI: 1578748877
Provider Name (Legal Business Name): IRDGAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9375 SAN FERNANDO RD
SUN VALLEY CA
91352-1418
US

IV. Provider business mailing address

9375 SAN FERNANDO RD
SUN VALLEY CA
91352-1418
US

V. Phone/Fax

Practice location:
  • Phone: 818-768-3322
  • Fax: 818-504-0418
Mailing address:
  • Phone: 818-768-3322
  • Fax: 818-504-0418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHY406210
License Number StateCA

VIII. Authorized Official

Name: DR. RONALD DENNIS MANZANI
Title or Position: PRESIDENT
Credential: PHARM. D.
Phone: 818-768-3322