Provider Demographics
NPI:1013345206
Name:MOEZIVAZIRI, JAMILEH
Entity Type:Individual
Prefix:
First Name:JAMILEH
Middle Name:
Last Name:MOEZIVAZIRI
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 1:1161 LAKE AVE APT 326
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-2455
Mailing Address - Country:US
Mailing Address - Phone:504-339-1982
Mailing Address - Fax:
Practice Address - Street 1:7777 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1632
Practice Address - Country:US
Practice Address - Phone:225-766-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPNT.046986183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist