MEDICARE: KASRA MANOUCHEHRIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	78180	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	78180	OTHER	CA	PHARMACIST

General Provider Information

NPI Number	:	1326533548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASRA MANOUCHEHRIAN

Provider Business Mailing Address
First Line	:	PO BOX 1126
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91740-1126
Country	:	US
Telephone Number	:	626-675-5713
Fax Number	:

Provider Business Practice Location Address
First Line	:	10349 SEPULVEDA BLVD
Second Line	:
City	:	MISSION HILLS
State	:	CA
Zip	:	91345-2421
Country	:	US
Telephone Number	:	818-891-1941
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2018
Last Update Date	:	05/18/2019

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