Provider Demographics
NPI:1871327692
Name:OGTANYAN, SHANT
Entity type:Individual
Prefix:
First Name:SHANT
Middle Name:
Last Name:OGTANYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17051 HORACE ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4922
Mailing Address - Country:US
Mailing Address - Phone:818-312-2161
Mailing Address - Fax:
Practice Address - Street 1:411 N CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1898
Practice Address - Country:US
Practice Address - Phone:818-244-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist