Provider Demographics
NPI:1760845374
Name:GHAVIDEL, MOJTABA
Entity Type:Individual
Prefix:MR
First Name:MOJTABA
Middle Name:
Last Name:GHAVIDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-1400
Mailing Address - Country:US
Mailing Address - Phone:508-359-6855
Mailing Address - Fax:508-359-6855
Practice Address - Street 1:230 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-1400
Practice Address - Country:US
Practice Address - Phone:508-359-6855
Practice Address - Fax:508-359-7519
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH22432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist