Provider Demographics
NPI:1497042089
Name:SIAHPOUSHAN, SHIRIN
Entity Type:Individual
Prefix:MRS
First Name:SHIRIN
Middle Name:
Last Name:SIAHPOUSHAN
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 1:4390 MONTGOMERY RD
Mailing Address - Street 2:T-1042
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6068
Mailing Address - Country:US
Mailing Address - Phone:410-203-1171
Mailing Address - Fax:410-203-1171
Practice Address - Street 1:4390 MONTGOMERY RD
Practice Address - Street 2:T-1042
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6068
Practice Address - Country:US
Practice Address - Phone:410-203-1171
Practice Address - Fax:410-203-1171
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist