Provider Demographics
NPI:1255658407
Name:SIAVOSHAN, MASIH (RPH)
Entity Type:Individual
Prefix:MR
First Name:MASIH
Middle Name:
Last Name:SIAVOSHAN
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 1:6224 OLD DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4217
Mailing Address - Country:US
Mailing Address - Phone:703-538-6600
Mailing Address - Fax:703-241-7023
Practice Address - Street 1:6224 OLD DOMINION DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4217
Practice Address - Country:US
Practice Address - Phone:703-538-6600
Practice Address - Fax:703-241-7023
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202012184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist