Provider Demographics
NPI:1710519202
Name:KHORRAMDIN, MAHSA
Entity Type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:KHORRAMDIN
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 1:741 WOODHAMS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5633
Mailing Address - Country:US
Mailing Address - Phone:408-747-7791
Mailing Address - Fax:
Practice Address - Street 1:99 MONTECILLO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3308
Practice Address - Country:US
Practice Address - Phone:415-444-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist