Healthcare Provider Details

I. General information

NPI: 1619809902
Provider Name (Legal Business Name): SOODABEH PESSIAN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8751 RED OAK DR
EDEN PRAIRIE MN
55347-2357
US

IV. Provider business mailing address

8751 RED OAK DR
EDEN PRAIRIE MN
55347-2357
US

V. Phone/Fax

Practice location:
  • Phone: 612-747-8496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number116169
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: