Provider Demographics
NPI:1992392922
Name:SADDI, JALAL ELIAS
Entity Type:Individual
Prefix:
First Name:JALAL
Middle Name:ELIAS
Last Name:SADDI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12071 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5173
Mailing Address - Country:US
Mailing Address - Phone:909-514-0287
Mailing Address - Fax:
Practice Address - Street 1:12071 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5173
Practice Address - Country:US
Practice Address - Phone:909-514-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist