Provider Demographics
NPI:1811580137
Name:LICERIO, CAMILLA DIVINA GALUT
Entity Type:Individual
Prefix:
First Name:CAMILLA DIVINA
Middle Name:GALUT
Last Name:LICERIO
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 1:2732 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2633
Mailing Address - Country:US
Mailing Address - Phone:213-382-6391
Mailing Address - Fax:
Practice Address - Street 1:2732 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2633
Practice Address - Country:US
Practice Address - Phone:213-382-6391
Practice Address - Fax:213-387-7475
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA144493183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician