Provider Demographics
NPI:1477986594
Name:KUBAO, EVERLYN
Entity Type:Individual
Prefix:
First Name:EVERLYN
Middle Name:
Last Name:KUBAO
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 1:3335 APPLETON ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1701
Mailing Address - Country:US
Mailing Address - Phone:323-283-5794
Mailing Address - Fax:
Practice Address - Street 1:1625 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4226
Practice Address - Country:US
Practice Address - Phone:213-482-9286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist