Healthcare Provider Details

I. General information

NPI: 1114308897
Provider Name (Legal Business Name): MR. AMIR ZIAEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S MAIN ST SAFEWAY PHARMACY 0965
WILLITS CA
95490-3915
US

IV. Provider business mailing address

845 S MAIN ST SAFEWAY PHARMACY 0965
WILLITS CA
95490-3915
US

V. Phone/Fax

Practice location:
  • Phone: 707-456-1790
  • Fax: 707-456-1794
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number71171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: