Provider Demographics
NPI:1720309701
Name:DRAGOVICH, GARY M (PHM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:DRAGOVICH
Suffix:
Gender:M
Credentials:PHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 WEST SEPULVEDA AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-5301
Mailing Address - Country:US
Mailing Address - Phone:310-325-0868
Mailing Address - Fax:310-356-6486
Practice Address - Street 1:2240 WEST SEPULVEDA AVE.
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-5301
Practice Address - Country:US
Practice Address - Phone:310-325-0868
Practice Address - Fax:310-356-6486
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist