Provider Demographics
NPI:1003373473
Name:PIROOZ, FARZAD JACK
Entity Type:Individual
Prefix:
First Name:FARZAD
Middle Name:JACK
Last Name:PIROOZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11504 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3008
Mailing Address - Country:US
Mailing Address - Phone:310-479-0200
Mailing Address - Fax:310-479-0220
Practice Address - Street 1:11504 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3008
Practice Address - Country:US
Practice Address - Phone:310-479-0200
Practice Address - Fax:310-479-0220
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist