Provider Demographics
NPI:1144942566
Name:MIRFAKHAR, SEYED ALI
Entity type:Individual
Prefix:
First Name:SEYED ALI
Middle Name:
Last Name:MIRFAKHAR
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 1:3895 W BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1017
Mailing Address - Country:US
Mailing Address - Phone:954-316-6641
Mailing Address - Fax:
Practice Address - Street 1:3895 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1017
Practice Address - Country:US
Practice Address - Phone:954-316-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34838183500000X
FL64838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist