Provider Demographics
NPI:1790049484
Name:PETICUB
Entity Type:Organization
Organization Name:PETICUB
Other - Org Name:PETICUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LOCATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RABIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAOULIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-839-7387
Mailing Address - Street 1:1804 S LA CIENEGA BLVD # 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-4670
Mailing Address - Country:US
Mailing Address - Phone:310-839-7387
Mailing Address - Fax:310-288-9141
Practice Address - Street 1:1804 S LA CIENEGA BLVD # 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-4670
Practice Address - Country:US
Practice Address - Phone:310-839-7387
Practice Address - Fax:310-288-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5644821OtherNCPDP PROVIDER IDENTIFICATION NUMBER