Healthcare Provider Details

I. General information

NPI: 1922357524
Provider Name (Legal Business Name): KATAYOUN SOPHIA GHAZANFARI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 SOUTHERN BLVD
RIO RANCHO NM
87124
US

IV. Provider business mailing address

6112 STARGAZR NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-8244
  • Fax:
Mailing address:
  • Phone: 505-440-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007884
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: