MEDICARE: 4 LIFE RX INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY45089	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1996798	OTHER		PK

General Provider Information

NPI Number	:	1275620460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4 LIFE RX INC

Provider Business Mailing Address
First Line	:	19554 VENTURA BLVD
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-2917
Country	:	US
Telephone Number	:	818-342-2636
Fax Number	:	818-342-3380

Provider Business Practice Location Address
First Line	:	19554 VENTURA BLVD
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-2917
Country	:	US
Telephone Number	:	818-342-2636
Fax Number	:	818-342-3380

Authorized Official
Title or Position	:	CEO
Name	:	VAHE GEORGE GARIBIAN
Credential	:
Telephone Number	:	818-342-2636

Provider Enumeration Date	:	10/07/2006
Last Update Date	:	03/23/2017

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Directions to “4 LIFE RX INC ” Practice Location

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