Provider Demographics
NPI:1477254241
Name:MOHTADI, SHEIDA S
Entity type:Individual
Prefix:
First Name:SHEIDA
Middle Name:S
Last Name:MOHTADI
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 1:10488 EASTBORNE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6158
Mailing Address - Country:US
Mailing Address - Phone:310-774-1650
Mailing Address - Fax:
Practice Address - Street 1:10488 EASTBORNE AVE APT 304
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-6158
Practice Address - Country:US
Practice Address - Phone:310-774-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist