Healthcare Provider Details

I. General information

NPI: 1629395165
Provider Name (Legal Business Name): MARYAM FARROKHROO PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11975 EL CAMINO REAL STE 101
SAN DIEGO CA
92130-2541
US

IV. Provider business mailing address

160 KAZAN ST
IRVINE CA
92604-2457
US

V. Phone/Fax

Practice location:
  • Phone: 949-390-4520
  • Fax:
Mailing address:
  • Phone: 949-390-4520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number56196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: