Provider Demographics
NPI:1518794809
Name:YAZDANYAR, ETHAN (CPHT)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:YAZDANYAR
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-1529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 S WEST END BLVD
Practice Address - Street 2:
Practice Address - City:QUAKERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18951-5207
Practice Address - Country:US
Practice Address - Phone:610-730-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30277116183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician