Provider Demographics
NPI:1952055279
Name:ALLEN, DAVIERE
Entity Type:Individual
Prefix:
First Name:DAVIERE
Middle Name:
Last Name:ALLEN
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 1:4571 ORCHID DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3320
Mailing Address - Country:US
Mailing Address - Phone:323-819-3684
Mailing Address - Fax:
Practice Address - Street 1:2900 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2788
Practice Address - Country:US
Practice Address - Phone:323-819-3684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20852183500000X
CA84435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist