Provider Demographics
NPI:1376916049
Name:FARDADFARD, MARJAN P (PHARMD, CGP)
Entity Type:Individual
Prefix:
First Name:MARJAN
Middle Name:P
Last Name:FARDADFARD
Suffix:
Gender:F
Credentials:PHARMD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-7803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4149 HIGHLINE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-2097
Practice Address - Country:US
Practice Address - Phone:800-940-9963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK145651835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist