Provider Demographics
NPI:1598207789
Name:BEDROSIAN, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BEDROSIAN
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 1:321 E ALAMEDA AVE
Mailing Address - Street 2:STE L
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2616
Mailing Address - Country:US
Mailing Address - Phone:818-563-6655
Mailing Address - Fax:
Practice Address - Street 1:321 E ALAMEDA AVE
Practice Address - Street 2:STE L
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-2616
Practice Address - Country:US
Practice Address - Phone:818-563-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-06
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 41687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336130186Medicaid
1323710001Medicare NSC