Provider Demographics
NPI:1093050619
Name:RAFIEI, BANOU (PHARM D)
Entity Type:Individual
Prefix:
First Name:BANOU
Middle Name:
Last Name:RAFIEI
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 E BERNADA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4747
Mailing Address - Country:US
Mailing Address - Phone:801-347-3188
Mailing Address - Fax:
Practice Address - Street 1:1837 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-1103
Practice Address - Country:US
Practice Address - Phone:801-967-0682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7125555-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist