Healthcare Provider Details

I. General information

NPI: 1588496590
Provider Name (Legal Business Name): JOSEPH ELISHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18441 VENTURA BLVD
TARZANA CA
91356-4201
US

IV. Provider business mailing address

5310 ZELZAH AVE UNIT 306
ENCINO CA
91316-2265
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1000
  • Fax:
Mailing address:
  • Phone: 310-729-4083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number179846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: