Provider Demographics
NPI:1437694650
Name:MAGHSOUDLOU, DARIA
Entity Type:Individual
Prefix:
First Name:DARIA
Middle Name:
Last Name:MAGHSOUDLOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-2020
Mailing Address - Country:US
Mailing Address - Phone:575-840-0334
Mailing Address - Fax:
Practice Address - Street 1:1835 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5168
Practice Address - Country:US
Practice Address - Phone:575-624-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-24
Last Update Date:2016-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist