Provider Demographics
NPI:1326341454
Name:KHACHATRYAN, LUSINE
Entity Type:Individual
Prefix:
First Name:LUSINE
Middle Name:
Last Name:KHACHATRYAN
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 1:17390 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6153
Mailing Address - Country:US
Mailing Address - Phone:760-948-2445
Mailing Address - Fax:760-947-4317
Practice Address - Street 1:7789 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-2137
Practice Address - Country:US
Practice Address - Phone:818-353-5817
Practice Address - Fax:818-353-7867
Is Sole Proprietor?:No
Enumeration Date:2010-12-11
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist