MEDICARE: DR. DOR KEYVANI PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	75634	CA
2	183500000X	Pharmacist	75634	CA

General Provider Information

NPI Number	:	1578005559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOR KEYVANI PHARM.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 3513
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 WESTWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6328
Country	:	US
Telephone Number	:	310-351-9979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2016
Last Update Date	:	01/13/2021

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