Provider Demographics
NPI:1679634315
Name:KHORSANDI, HOMAYOON B (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:HOMAYOON
Middle Name:B
Last Name:KHORSANDI
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 1:2222 SANTA MONICA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2305
Mailing Address - Country:US
Mailing Address - Phone:310-453-5557
Mailing Address - Fax:310-828-5536
Practice Address - Street 1:2222 SANTA MONICA BLVD. #103
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2304
Practice Address - Country:US
Practice Address - Phone:310-453-5557
Practice Address - Fax:310-828-5536
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-98877OtherNABP #
CAPHA395200Medicaid
CA5542170001Medicare ID - Type Unspecified