Healthcare Provider Details

I. General information

NPI: 1821388265
Provider Name (Legal Business Name): SHIVA VAZIRI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11609 S SAGINAW ST
GRAND BLANC MI
48439-1354
US

IV. Provider business mailing address

1305 KINGS POINTE RD
GRAND BLANC MI
48439-8672
US

V. Phone/Fax

Practice location:
  • Phone: 810-694-4611
  • Fax:
Mailing address:
  • Phone: 810-695-4421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302028887
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: