Healthcare Provider Details

I. General information

NPI: 1184346942
Provider Name (Legal Business Name): SHAHRYAR MAHDIYOUN PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S WAHANNA RD
SEASIDE OR
97138-7735
US

IV. Provider business mailing address

1212 N 10TH ST # A
COOS BAY OR
97420-1981
US

V. Phone/Fax

Practice location:
  • Phone: 503-717-7307
  • Fax:
Mailing address:
  • Phone: 541-290-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-00009917
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: