Provider Demographics
NPI:1629423348
Name:KHODABAKHSHI, SOHAIL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SOHAIL
Middle Name:
Last Name:KHODABAKHSHI
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 1:10905 OHIO AVENUE
Mailing Address - Street 2:APT 312
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024
Mailing Address - Country:US
Mailing Address - Phone:901-335-1592
Mailing Address - Fax:
Practice Address - Street 1:747 WESTWOOD PLAZA
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-267-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38017Medicaid
CA38018Medicaid
CA38018Medicaid
CA38021Medicare UPIN