Organization
GRACELIGHT COMMUNITY HEALTH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARINA SNITMAN PHARMD (CHIEF OPERATING OFFICER)
(323) 635-1153
Entity
Organization
Contact information
Practice address
4816 E 3RD ST, LOS ANGELES, CA 90022-1602
(323) 780-4510
(323) 780-6132
Mailing address
4816 E 3RD ST, LOS ANGELES, CA 90022-1602
(323) 635-1153
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0002X
Clinic Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
55-1019
MEDICARE FQHC PROVIDER NUMBER
CA
05
—
CMM70660F
—
CA
01
—
PHY 52564
CALIFORNIA PHARMACY LICENSE
CA
01
—
W6997D
MEDICARE PROVIDER NUMBER
CA
Enumeration date
09/09/2014
Last updated
05/20/2024
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