Provider Demographics
NPI:1275620460
Name:4 LIFE RX INC
Entity Type:Organization
Organization Name:4 LIFE RX INC
Other - Org Name:4 LIFE RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VAHE GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARIBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-342-2636
Mailing Address - Street 1:19554 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2917
Mailing Address - Country:US
Mailing Address - Phone:818-342-2636
Mailing Address - Fax:818-342-3380
Practice Address - Street 1:19554 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2917
Practice Address - Country:US
Practice Address - Phone:818-342-2636
Practice Address - Fax:818-342-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY450893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA450890Medicaid
1996798OtherPK
CAPHA450890Medicaid