MEDICARE: MR. GENNADY MAZIN PHARMACY TECH

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	183700000X	Pharmacy Technician	TCH 59900	CA

General Provider Information

NPI Number	:	1427267111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GENNADY MAZIN PHARMACY TECH

Provider Business Mailing Address
First Line	:	4401 MOORPARK WAY APT 108
Second Line	:
City	:	TOLUCA LAKE
State	:	CA
Zip	:	91602-2471
Country	:	US
Telephone Number	:	818-508-7266
Fax Number	:

Provider Business Practice Location Address
First Line	:	7722 SANTA MONICA BLVD
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-6220
Country	:	US
Telephone Number	:	323-656-3663
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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