Provider Demographics
NPI:1477967255
Name:DERKALOSTIAN, ALINE
Entity Type:Individual
Prefix:
First Name:ALINE
Middle Name:
Last Name:DERKALOSTIAN
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 1:759 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4813
Mailing Address - Country:US
Mailing Address - Phone:714-803-8345
Mailing Address - Fax:
Practice Address - Street 1:1720 AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-2810
Practice Address - Country:US
Practice Address - Phone:310-376-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist