Healthcare Provider Details

I. General information

NPI: 1740592740
Provider Name (Legal Business Name): VAHID MAHMOUDI PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10631 TIERRASANTA BLVD
SAN DIEGO CA
92124-2605
US

IV. Provider business mailing address

12165 LICIA WAY
SAN DIEGO CA
92129-3768
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-0972
  • Fax: 858-576-0035
Mailing address:
  • Phone: 858-538-0859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number55499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: