Provider Demographics
NPI:1407543697
Name:KESHAVARZ, MOJDEH (CPHT)
Entity Type:Individual
Prefix:
First Name:MOJDEH
Middle Name:
Last Name:KESHAVARZ
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28019 RIDGEBLUFF CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-7206
Mailing Address - Country:US
Mailing Address - Phone:310-971-3217
Mailing Address - Fax:
Practice Address - Street 1:23 PENINSULA CTR
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3506
Practice Address - Country:US
Practice Address - Phone:310-377-4472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA91783333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy