Provider Demographics
NPI:1760909915
Name:JAMALEDDIN, SHADI
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:JAMALEDDIN
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 1:27066 PACIFIC TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5001
Mailing Address - Country:US
Mailing Address - Phone:818-399-7866
Mailing Address - Fax:
Practice Address - Street 1:27066 PACIFIC TERRACE DR
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-5001
Practice Address - Country:US
Practice Address - Phone:818-399-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist