Provider Demographics
NPI:1376044388
Name:BOOSTANI, NEGIN
Entity Type:Individual
Prefix:
First Name:NEGIN
Middle Name:
Last Name:BOOSTANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 17TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1247 17TH ST APT 5
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1215
Practice Address - Country:US
Practice Address - Phone:310-279-0468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist