Healthcare Provider Details

I. General information

NPI: 1003373473
Provider Name (Legal Business Name): FARZAD JACK PIROOZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11504 SANTA MONICA BLVD
LOS ANGELES CA
90025-3008
US

IV. Provider business mailing address

11504 SANTA MONICA BLVD
LOS ANGELES CA
90025-3008
US

V. Phone/Fax

Practice location:
  • Phone: 310-479-0200
  • Fax: 310-479-0220
Mailing address:
  • Phone: 310-479-0200
  • Fax: 310-479-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number48428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: