MEDICARE: PETICUB

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	3336M0002X	Mail Order Pharmacy
2	3336H0001X	Home Infusion Therapy Pharmacy
3	3336C0004X	Compounding Pharmacy
4	333600000X	Pharmacy
5	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5644821	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1790049484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETICUB

Provider Business Mailing Address
First Line	:	1804 S LA CIENEGA BLVD # 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4670
Country	:	US
Telephone Number	:	310-839-7387
Fax Number	:	310-288-9141

Provider Business Practice Location Address
First Line	:	1804 S LA CIENEGA BLVD # 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4670
Country	:	US
Telephone Number	:	310-839-7387
Fax Number	:	310-288-9141

Authorized Official
Title or Position	:	LOCATION MANAGER
Name	:	RABIN SHAOULIAN
Credential	:
Telephone Number	:	310-839-7387

Provider Enumeration Date	:	06/27/2012
Last Update Date	:	08/21/2012

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Directions to “PETICUB ” Practice Location

Language	Start Address	Practice Location

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