Provider Demographics
NPI:1164850723
Name:SASAN, MOHAMMAD REZA (RPH)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD REZA
Middle Name:
Last Name:SASAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19200 SW MARTINAZZI AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-6357
Mailing Address - Country:US
Mailing Address - Phone:503-691-4233
Mailing Address - Fax:503-691-4220
Practice Address - Street 1:19200 SW MARTINAZZI AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6357
Practice Address - Country:US
Practice Address - Phone:503-691-4233
Practice Address - Fax:503-691-4220
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13388183500000X
TX35947183500000X
OR00133881835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist