MEDICARE: KATHLEEN ANNE ELEVAZO NICANOR PHARMD, RPH

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	RP455752	PA
2	183500000X	Pharmacist	RPH86761	CA

General Provider Information

NPI Number	:	1255056537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN ANNE ELEVAZO NICANOR PHARMD, RPH

Provider Business Mailing Address
First Line	:	2647 S BARRINGTON AVE APT 9
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2852
Country	:	US
Telephone Number	:	510-493-8448
Fax Number	:

Provider Business Practice Location Address
First Line	:	2647 S BARRINGTON AVE APT 9
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2852
Country	:	US
Telephone Number	:	510-493-8448
Fax Number	:

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

Provider Enumeration Date	:	10/10/2022
Last Update Date	:	10/10/2022

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