Provider Demographics
NPI:1891065660
Name:KHOSRAVI MOGHADAM, SHIVA (RPH)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:KHOSRAVI MOGHADAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12430 93RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-5913
Mailing Address - Country:US
Mailing Address - Phone:818-744-0283
Mailing Address - Fax:
Practice Address - Street 1:12405 NE 85TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-8032
Practice Address - Country:US
Practice Address - Phone:425-822-9202
Practice Address - Fax:425-822-9407
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00043094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist