Provider Demographics
NPI:1588138796
Name:KELEKIAN, CRISTINA
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:KELEKIAN
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 1:9256 SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4526
Mailing Address - Country:US
Mailing Address - Phone:562-949-5424
Mailing Address - Fax:
Practice Address - Street 1:9256 SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4526
Practice Address - Country:US
Practice Address - Phone:562-949-5424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487698759Medicaid
18OtherPHARMACIST
CA18Medicaid