Provider Demographics
NPI:1447968094
Name:DAVTYAN, VICKY
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:DAVTYAN
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 1:1699 ROYAL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-1557
Mailing Address - Country:US
Mailing Address - Phone:818-522-0033
Mailing Address - Fax:
Practice Address - Street 1:18430 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4305
Practice Address - Country:US
Practice Address - Phone:818-343-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist