Provider Demographics
NPI:1346595634
Name:DERBOGHOSSIAN, ANI HAGOP (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:ANI
Middle Name:HAGOP
Last Name:DERBOGHOSSIAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 W CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-3805
Mailing Address - Country:US
Mailing Address - Phone:559-264-8698
Mailing Address - Fax:
Practice Address - Street 1:1344 W CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-3805
Practice Address - Country:US
Practice Address - Phone:559-264-8698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist