Provider Demographics
NPI:1003524703
Name:BAHARI MOGHADAM, SHANNON (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BAHARI MOGHADAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10660 WILSHIRE BLVD APT 310
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4523
Mailing Address - Country:US
Mailing Address - Phone:424-230-2122
Mailing Address - Fax:
Practice Address - Street 1:9045 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1829
Practice Address - Country:US
Practice Address - Phone:310-273-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist