Provider Demographics
NPI:1164230512
Name:LGDM
Entity type:Organization
Organization Name:LGDM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GEVORKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:818-853-2800
Mailing Address - Street 1:800 S CENTRAL AVE STE 101A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4375
Mailing Address - Country:US
Mailing Address - Phone:818-319-3046
Mailing Address - Fax:
Practice Address - Street 1:800 S CENTRAL AVE STE 101A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4375
Practice Address - Country:US
Practice Address - Phone:818-319-3046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEWEL PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy