Healthcare Provider Details

I. General information

NPI: 1558819250
Provider Name (Legal Business Name): MITRA RASTEGAR PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 S SAN VICENTE BLVD STE 104
LOS ANGELES CA
90048-4166
US

IV. Provider business mailing address

444 S SAN VICENTE BLVD STE 104
LOS ANGELES CA
90048-4166
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-9550
  • Fax: 310-423-9551
Mailing address:
  • Phone: 310-423-9550
  • Fax: 310-423-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRPH 53999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: