Healthcare Provider Details

I. General information

NPI: 1871685446
Provider Name (Legal Business Name): OMID KHONSARI PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E CARSON ST SUITE 104
CARSON CA
90745-2262
US

IV. Provider business mailing address

PO BOX 5977
BEVERLY HILLS CA
90209-5977
US

V. Phone/Fax

Practice location:
  • Phone: 310-847-7624
  • Fax:
Mailing address:
  • Phone: 310-849-9587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15432
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: