Provider Demographics
NPI:1346679883
Name:PETROVIC, JELICA
Entity Type:Individual
Prefix:
First Name:JELICA
Middle Name:
Last Name:PETROVIC
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 1:3237 PROVON LN
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-2714
Mailing Address - Country:US
Mailing Address - Phone:310-466-4007
Mailing Address - Fax:
Practice Address - Street 1:3237 PROVON LN
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-2714
Practice Address - Country:US
Practice Address - Phone:310-466-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist