MEDICARE: GRIGOR DEREMSEZYAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	77909	CA

General Provider Information

NPI Number	:	1215591490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRIGOR DEREMSEZYAN

Provider Business Mailing Address
First Line	:	581 W CHANNEL ISLANDS BLVD
Second Line	:
City	:	PORT HUENEME
State	:	CA
Zip	:	93041-2133
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	581 W CHANNEL ISLANDS BLVD
Second Line	:
City	:	PORT HUENEME
State	:	CA
Zip	:	93041-2133
Country	:	US
Telephone Number	:	805-985-4479
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	04/23/2019

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Directions to “ GRIGOR DEREMSEZYAN ” Practice Location

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