Provider Demographics
NPI:1013514074
Name:MEHDIZADEH, MIRZAALI VAGASLO (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MIRZAALI
Middle Name:VAGASLO
Last Name:MEHDIZADEH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CRYSTAL CT
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-3543
Mailing Address - Country:US
Mailing Address - Phone:469-471-3375
Mailing Address - Fax:
Practice Address - Street 1:502 N VALLEY PKWY # 1A
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3437
Practice Address - Country:US
Practice Address - Phone:469-949-1003
Practice Address - Fax:469-949-1004
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist