Provider Demographics
NPI:1770677783
Name:IMRAN, SABAHAT LATIF (MPHARM)
Entity Type:Individual
Prefix:
First Name:SABAHAT
Middle Name:LATIF
Last Name:IMRAN
Suffix:
Gender:M
Credentials:MPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-1508
Mailing Address - Country:US
Mailing Address - Phone:707-571-4354
Mailing Address - Fax:707-571-4604
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:KAISER MEDICAL CENTER
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-571-4354
Practice Address - Fax:707-571-4604
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist