Provider Demographics
NPI:1437564564
Name:GHAEDI, EVA
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:GHAEDI
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 1:6091 MER ROUGE RD
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-6709
Mailing Address - Country:US
Mailing Address - Phone:318-281-3564
Mailing Address - Fax:318-283-6058
Practice Address - Street 1:6091 MER ROUGE RD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-6709
Practice Address - Country:US
Practice Address - Phone:318-281-3564
Practice Address - Fax:318-283-6058
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist