Provider Demographics
NPI:1689710295
Name:VICKEN GULVARTIAN
Entity Type:Organization
Organization Name:VICKEN GULVARTIAN
Other - Org Name:IDEAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GULVARTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-851-6800
Mailing Address - Street 1:7095 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-8903
Mailing Address - Country:US
Mailing Address - Phone:323-851-6800
Mailing Address - Fax:323-851-6801
Practice Address - Street 1:7095 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-8903
Practice Address - Country:US
Practice Address - Phone:323-851-6800
Practice Address - Fax:323-851-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY310413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA310410Medicaid
0582230OtherNCPDP PROVIDER IDENTIFICATION NUMBER