Provider Demographics
NPI:1528016862
Name:WEST LOS ANGELES VAMC
Entity Type:Organization
Organization Name:WEST LOS ANGELES VAMC
Other - Org Name:WEST LA VAMC - METHADONE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94424
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4424
Mailing Address - Country:US
Mailing Address - Phone:702-341-3152
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3152
Practice Address - Fax:310-268-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0521965OtherNCPDP#