Provider Demographics
NPI:1942961693
Name:DERAKHSHANI JAN, SANAZ
Entity Type:Individual
Prefix:
First Name:SANAZ
Middle Name:
Last Name:DERAKHSHANI JAN
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 1:4046 S CENTINELA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4046 S CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4907
Practice Address - Country:US
Practice Address - Phone:818-913-9338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist