Provider Demographics
NPI:1114372604
Name:GHODOUMIPOUR, ABBAS
Entity Type:Individual
Prefix:
First Name:ABBAS
Middle Name:
Last Name:GHODOUMIPOUR
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 1:24372 ROCKFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4742
Mailing Address - Country:US
Mailing Address - Phone:949-830-5090
Mailing Address - Fax:940-830-9419
Practice Address - Street 1:24372 ROCKFIELD BLVD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4742
Practice Address - Country:US
Practice Address - Phone:949-830-5090
Practice Address - Fax:940-830-9419
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist