Provider Demographics
NPI:1477823367
Name:DANESH, FOROUZAN
Entity Type:Individual
Prefix:
First Name:FOROUZAN
Middle Name:
Last Name:DANESH
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 1:10200 MUKILTEO SPEEDWAY
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-4743
Mailing Address - Country:US
Mailing Address - Phone:425-315-9213
Mailing Address - Fax:425-315-9553
Practice Address - Street 1:10200 MUKILTEO SPEEDWAY
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-4743
Practice Address - Country:US
Practice Address - Phone:425-315-9213
Practice Address - Fax:425-315-9553
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00043370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist