=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386974376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE CARE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2010
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5101 SANTA MONICA BLVD #6
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-426-9990
-----------------------------------------------------
Fax | 323-522-3611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5101 SANTA MONICA BLVD #6
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-426-9990
-----------------------------------------------------
Fax | 323-522-3611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | MRS. LUSIK L. DAVTYAN
-----------------------------------------------------
Credential | PHARMACY TECH
-----------------------------------------------------
Telephone | 323-426-9990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY 54582
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------