Provider Demographics
NPI:1518534148
Name:MOGHADAM, BIJAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BIJAN
Middle Name:
Last Name:MOGHADAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:CO
Mailing Address - Zip Code:81226-1213
Mailing Address - Country:US
Mailing Address - Phone:213-255-9817
Mailing Address - Fax:
Practice Address - Street 1:1520 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1207
Practice Address - Country:US
Practice Address - Phone:719-404-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist