Provider Demographics
NPI:1861776221
Name:ROSTAMNEZHAD, BEHROUZ (RPH)
Entity type:Individual
Prefix:
First Name:BEHROUZ
Middle Name:
Last Name:ROSTAMNEZHAD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458
Mailing Address - Country:US
Mailing Address - Phone:617-527-1563
Mailing Address - Fax:617-527-1565
Practice Address - Street 1:153 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1023
Practice Address - Country:US
Practice Address - Phone:617-527-1563
Practice Address - Fax:617-527-1565
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH23429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist