Provider Demographics
NPI:1629675509
Name:KADIVAR, SHRINA
Entity Type:Individual
Prefix:
First Name:SHRINA
Middle Name:
Last Name:KADIVAR
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 1:11943 KIOWA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5913
Mailing Address - Country:US
Mailing Address - Phone:310-940-0455
Mailing Address - Fax:
Practice Address - Street 1:13085 CENTRAL AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4184
Practice Address - Country:US
Practice Address - Phone:909-927-8323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist