Healthcare Provider Details

I. General information

NPI: 1205310901
Provider Name (Legal Business Name): BAHAREH RACHEL BANAFSHEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 N ROXBURY DR
BEVERLY HILLS CA
90210-5001
US

IV. Provider business mailing address

10560 WILSHIRE BLVD
LOS ANGELES CA
90024-4580
US

V. Phone/Fax

Practice location:
  • Phone: 310-271-6123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number75754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: