Provider Demographics
NPI:1902406473
Name:DERAKHSHAN, SANAZ
Entity Type:Individual
Prefix:
First Name:SANAZ
Middle Name:
Last Name:DERAKHSHAN
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 1:42015 VILLAGE CENTER PLZ
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3033
Mailing Address - Country:US
Mailing Address - Phone:703-944-0099
Mailing Address - Fax:
Practice Address - Street 1:42952 BEACHALL ST
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-2013
Practice Address - Country:US
Practice Address - Phone:170-394-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty