Provider Demographics
NPI:1942278395
Name:SAFARPOUR, REZA MOHAMMAD (RPH)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:MOHAMMAD
Last Name:SAFARPOUR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 JUPITER DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3341
Mailing Address - Country:US
Mailing Address - Phone:801-272-0550
Mailing Address - Fax:
Practice Address - Street 1:4111 JUPITER DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3341
Practice Address - Country:US
Practice Address - Phone:801-272-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2797369-1701183500000X
WAPH00022047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2797369OtherSTATE LICENSE NUMBER
WAPH00022047OtherSTATE LICENSE NUMBER