Provider Demographics
NPI:1891447058
Name:MOGHADAM, SIMA
Entity Type:Individual
Prefix:
First Name:SIMA
Middle Name:
Last Name:MOGHADAM
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 1:10540 BLENHEIM AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-2118
Mailing Address - Country:US
Mailing Address - Phone:702-480-3074
Mailing Address - Fax:
Practice Address - Street 1:7260 S CIMARRON RD STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2137
Practice Address - Country:US
Practice Address - Phone:702-444-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist