Provider Demographics
NPI:1588773279
Name:NERCESSIAN, GARABET (RPH)
Entity type:Individual
Prefix:MR
First Name:GARABET
Middle Name:
Last Name:NERCESSIAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1315
Mailing Address - Country:US
Mailing Address - Phone:818-246-7156
Mailing Address - Fax:818-246-0558
Practice Address - Street 1:1127 E BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1315
Practice Address - Country:US
Practice Address - Phone:818-246-7156
Practice Address - Fax:818-246-0558
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY453053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA453050Medicaid
1071300001Medicare NSC
CA5551335Medicare UPIN