Provider Demographics
NPI:1407424476
Name:NAKISA, AZADEH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:AZADEH
Middle Name:
Last Name:NAKISA
Suffix:
Gender:F
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:CVS PHARMACY, 291 N MCDOWELL BLVD
Mailing Address - Street 2:291 N MCDOWELL BLVD
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CVS PHARMACY, 291 N MCDOWELL BLVD
Practice Address - Street 2:291 N MCDOWELL BLVD
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-778-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty