Provider Demographics
NPI:1255826665
Name:TAVAKKOLI ISFAHANI, SEID AMIR FARZAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:SEID AMIR FARZAN
Middle Name:
Last Name:TAVAKKOLI ISFAHANI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12555 GARDEN GROVE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1903
Mailing Address - Country:US
Mailing Address - Phone:714-636-0593
Mailing Address - Fax:714-636-7708
Practice Address - Street 1:12555 GARDEN GROVE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1903
Practice Address - Country:US
Practice Address - Phone:714-636-0593
Practice Address - Fax:714-636-7708
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist