Provider Demographics
NPI:1861932022
Name:MOSHTAEL, MANDANA
Entity type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:MOSHTAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4926 CANOGA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-3201
Mailing Address - Country:US
Mailing Address - Phone:310-869-9461
Mailing Address - Fax:
Practice Address - Street 1:4926 CANOGA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-3201
Practice Address - Country:US
Practice Address - Phone:310-869-9461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH76062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist