Healthcare Provider Details

I. General information

NPI: 1427538313
Provider Name (Legal Business Name): PUSHTANA FAZLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W LODI AVE
LODI CA
95240-3425
US

IV. Provider business mailing address

1754 FLEABANE LN
MANTECA CA
95337-8615
US

V. Phone/Fax

Practice location:
  • Phone: 209-368-5363
  • Fax:
Mailing address:
  • Phone: 209-275-8438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number78464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: