Healthcare Provider Details

I. General information

NPI: 1497816789
Provider Name (Legal Business Name): AZAR M MORTEZAIE PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MONTECILLO RD
SAN RAFAEL CA
94903-3308
US

IV. Provider business mailing address

99 MONTECILLO RD
SAN RAFAEL CA
94903-3308
US

V. Phone/Fax

Practice location:
  • Phone: 415-444-2047
  • Fax: 415-444-2077
Mailing address:
  • Phone: 415-444-2047
  • Fax: 415-444-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number36308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: