Provider Demographics
NPI:1083941975
Name:MOSHTAGHFARD, ALI
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MOSHTAGHFARD
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 1:1807 W HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-6749
Mailing Address - Country:US
Mailing Address - Phone:817-467-2182
Mailing Address - Fax:
Practice Address - Street 1:6551 FOREST HILL DR
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:TX
Practice Address - Zip Code:76140-1205
Practice Address - Country:US
Practice Address - Phone:817-478-2952
Practice Address - Fax:817-478-0942
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist