Provider Demographics
NPI:1689126708
Name:DADKHAH, MAHSA
Entity Type:Individual
Prefix:MISS
First Name:MAHSA
Middle Name:
Last Name:DADKHAH
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 1:602 N EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4720
Mailing Address - Country:US
Mailing Address - Phone:949-369-5281
Mailing Address - Fax:
Practice Address - Street 1:615 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3211
Practice Address - Country:US
Practice Address - Phone:323-268-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist