Provider Demographics
NPI:1508278417
Name:KANZALI, GLORIANN
Entity Type:Individual
Prefix:
First Name:GLORIANN
Middle Name:
Last Name:KANZALI
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 1:4051 WOODCREEK OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4051 WOODCREEK OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6812
Practice Address - Country:US
Practice Address - Phone:916-771-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH59613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist