Healthcare Provider Details

I. General information

NPI: 1699295477
Provider Name (Legal Business Name): NILOUFAR FAKHRACHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 N VALLE VERDE DR
HENDERSON NV
89074-1756
US

IV. Provider business mailing address

2842 YUKON TRAIL DR
HENDERSON NV
89074
US

V. Phone/Fax

Practice location:
  • Phone: 310-622-5304
  • Fax: 310-622-5304
Mailing address:
  • Phone: 310-622-5304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number72585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: