Provider Demographics
NPI:1013266568
Name:KHORDEHFOROSH, MOHSEN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MOHSEN
Middle Name:
Last Name:KHORDEHFOROSH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 SARDIS GREEN COURT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270
Mailing Address - Country:US
Mailing Address - Phone:704-301-3278
Mailing Address - Fax:
Practice Address - Street 1:1711 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205
Practice Address - Country:US
Practice Address - Phone:704-301-3278
Practice Address - Fax:704-366-1903
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist