Provider Demographics
NPI:1083063473
Name:LAW, IVAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:LAW
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 1:540 W PALMDALE BLVD # A
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4232
Mailing Address - Country:US
Mailing Address - Phone:661-267-2638
Mailing Address - Fax:661-267-0813
Practice Address - Street 1:540 W PALMDALE BLVD # A
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4232
Practice Address - Country:US
Practice Address - Phone:661-267-2638
Practice Address - Fax:661-267-0813
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist