Provider Demographics
NPI:1508630708
Name:MUSSAYAR, SHABNAM
Entity Type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:MUSSAYAR
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 1:29029 CARAVAN LN
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4761
Mailing Address - Country:US
Mailing Address - Phone:510-209-2778
Mailing Address - Fax:
Practice Address - Street 1:1650 DECOTO RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-3544
Practice Address - Country:US
Practice Address - Phone:510-429-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist