MEDICARE: VAKO MINAS AGAJANIAN

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	3336C0003X	Community/Retail Pharmacy	53780	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2153993	OTHER		PK

General Provider Information

NPI Number	:	1588665087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAKO MINAS AGAJANIAN

Provider Business Mailing Address
First Line	:	1729 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-2752
Country	:	US
Telephone Number	:	626-817-9828
Fax Number	:	626-817-9830

Provider Business Practice Location Address
First Line	:	1729 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-2752
Country	:	US
Telephone Number	:	626-817-9828
Fax Number	:	626-817-9830

Authorized Official
Title or Position	:	OWNER
Name	:	VAKO AGAJANIAN
Credential	:
Telephone Number	:	626-817-9828

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	10/22/2015

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