Provider Demographics
NPI:1801216346
Name:GHAEDI, DARYOUSH
Entity Type:Individual
Prefix:MR
First Name:DARYOUSH
Middle Name:
Last Name:GHAEDI
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 1:833 STERLINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-3805
Mailing Address - Country:US
Mailing Address - Phone:318-368-3280
Mailing Address - Fax:318-638-0142
Practice Address - Street 1:833 STERLINGTON HWY
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241-3805
Practice Address - Country:US
Practice Address - Phone:318-368-3280
Practice Address - Fax:318-368-0142
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist