Provider Demographics
NPI:1598376246
Name:SELEEM, MAZEN A
Entity Type:Individual
Prefix:
First Name:MAZEN
Middle Name:A
Last Name:SELEEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1467 BALHAN DR APT 106
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-3754
Mailing Address - Country:US
Mailing Address - Phone:415-374-0600
Mailing Address - Fax:
Practice Address - Street 1:1467 BALHAN DR APT 106
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-3754
Practice Address - Country:US
Practice Address - Phone:415-374-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80532183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist