Provider Demographics
NPI:1427469337
Name:YERGATIAN, LARA
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:YERGATIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 FOOTHILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7233
Mailing Address - Country:US
Mailing Address - Phone:916-783-1174
Mailing Address - Fax:916-783-5318
Practice Address - Street 1:4008 FOOTHILLS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7233
Practice Address - Country:US
Practice Address - Phone:916-783-1174
Practice Address - Fax:916-783-5318
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist